Implementation of mental health policies and reform in post-conflict countries: the case of post-genocide Rwanda

Abstract

The global burden of mental illness is rising, with populations in post-conflict countries contributing significantly to the numbers. Governments in these countries face the dual challenge of responding to increased mental health needs and implementing this response with institutions and economies weakened by war. This research studies the process, successes and challenges of implementing mental health reform in a low-resource, post-conflict country, a subject that is rarely studied. Based on fieldwork conducted in Rwanda in 2019, the study focuses on the implementation of this African country’s post-genocide mental health policy, which relies primarily on strategies of decentralization and integration into the primary health care system. The results are based on 30 interviews conducted in Kigali and Ngoma with primary stakeholders including government officials, representatives from nongovernmental organizations, service providers and academics. These stakeholders held a positive view of the main strategies of the policy as they resulted in increased accessibility and availability of care for Rwandans. However, they also noted the institutionalization and individualization of mental health care as gaps in the implementation that do not respond to the Rwandan context. Building on complexity theory, the analysis found that many of these gaps, as well as opportunities to address them, are missed by the government due to top-down implementation and a lack of collaboration with local organizations and service providers working in the domain. The research results suggest that although it is possible to prioritize mental health in low-resource, complex settings, the implementation of such reform requires collaborative, adaptive and horizontal approaches in order to adequately address and respond to citizen needs and ensure quality mental health care for all.

Health policy, mental health, health care reform, policy implementation, post-conflict, process

Key messages

• This qualitative study looks at the implementation of Rwanda’s post-genocide mental health policy to assess the challenges, successes and best practices of implementing mental health reform in a low-resource, post-conflict country.

• Strategies such as decentralization and integration of mental health care into the primary health care system can exponentially increase access to care and have the potential to be successful methods of implementing mental health reform in post-conflict countries, especially those lacking personnel, resources and financing.

• Institutionalization and individualization of mental health care can pose challenges to successful mental health policy implementation in post-conflict countries that have community-based societies and cultures.

• Mental health reform, especially in complex, low-resource settings, requires collaborative, adaptive and horizontal implementation styles involving stakeholders at all levels to adequately address and respond to citizen needs and ensure quality mental health care for all.

Introduction

The negative impact of conflict on mental health has been clearly documented in past research (Bryce et al., 1989; Mollica et al., 1993; Ahmad et al., 2000; Baingana, 2003; Murthy and Lakshminarayana, 2006; Charlson et al., 2019), including the consequences at the individual, community and national levels of failing to address post-conflict mental health concerns (Summerfield, 2000; Corey and Joireman, 2004; World Health Organization, 2007; Qouta et al., 2008). Despite this, few post-conflict countries have prioritized mental health reform in their post-conflict development plans. One exception is Rwanda, a small landlocked country in East Africa that introduced a mental health policy in 1995 after experiencing a devastating genocide and civil war. This article presents a case study using original research from this East African country to examine the process and challenges of implementing a mental health policy in a post-conflict country and to understand how mental health reform is navigated in complex settings.

Although some studies have assessed small-scale mental health programmes within Rwanda and others have looked at the prevalence of mental disorders in the country, this is the first study to specifically research the implementation of the policy. It is also one of few studies looking at mental health policy implementation in any post-conflict state. The study explicitly avoids evaluating the results of implementation, as there is currently no accepted framework for determining success of mental health policies, and any attempt at using standardized indicators or measures would likely miss important local nuances. Rather, this study traces the process of implementation in order to reveal the drivers and challenges, as well as the thoughts and opinions of those directly involved, highlighting the complex web of interactions that emerges during policy implementation.

The effect of conflict on mental health

The World Health Organization estimated in 2001 that 10% of people who experience traumatic events in situations of armed conflict will develop serious mental health problems and another 10% will develop behaviour that hinders their ability to function effectively (as cited in Murthy and Lakshminarayana, 2006). More recent studies have established a significant association between armed conflict and mental illness (Londoño et al., 2012; Jordans et al., 2016; Save the Children, 2017). According to the research, these mental health issues continue decades after the crisis is over and can have intergenerational consequences (Bryce et al., 1989; Ahmad et al., 2000, p. 239; Baingana, 2003).

Among adults living in post-conflict countries, studies have found the rates of post-traumatic stress disorder (PTSD) and depression to be between 17% and 80%, with most rates falling somewhere in the middle (Mollica et al., 1993, p. 581; Ahmad et al., 2000, p. 239). These studies have also found that women, children, the elderly and disabled individuals are the most vulnerable to psychological consequences of war (Murthy and Lakshminarayana, 2006, p. 25). In turn, poor mental health can lead to poor physical health, poverty, social exclusion and even loss of life. It can also have implications for peace and reconciliation: studies, including one conducted in Rwanda, have found that those suffering from poor mental health following a conflict are less likely to support restorative systems of transitional justice or peaceful methods of resolving conflicts and are more likely to exhibit aggressive behaviours (Corey and Joireman, 2004; Pham et al., 2004; Qouta et al., 2008).

Despite the abundance of research documenting the consequences of conflict on mental health, studies on the implementation of mental health policies in post-conflict countries remain rare. Two known studies are based in Bosnia Herzegovina and Kosovo (De Vries and Klazinga, 2006) and Cambodia (Stockwell et al., 2005), and both reached similar conclusions: stigma is a significant barrier to successful implementation, as is foreign influence leading to a lack of local ownership and sustainability. While these studies offer some insight into the implementation of mental health policies and reform in post-conflict countries, overall scientific research on the subject remains limited.

Mental health and conflict: the Rwandan case

Rwanda became a trailblazer for the African continent when it released and began implementing a national mental health policy in 1995 following the country’s genocide and civil war. The genocide in Rwanda erupted in 1994 following decades of ethnic tension and violence. This violence included 3 years of civil war between the Hutu-led Rwandan government and the Rwandan Patriotic Front (RPF), a rebel group comprised primarily of Tutsi refugees exiled to neighbouring countries in the years surrounding independence. The genocide took place in parallel to the civil war, which restarted following a brief period of peace. It was perpetrated by Hutu extremists against the Tutsi minority and moderate Hutus, resulting in approximately 800 000 deaths in only 3 months. Although not comparable in scale to the genocide, the RPF also killed thousands of predominantly Hutu civilians as they fought to take over the country (Des Forges, 1999). Throughout the genocide, much of the violence took place in public spaces, often within communities, and was also often perpetrated by community members against fellow community members. According to the Rwandan Ministry of Finance and Economic Planning, 99% of genocide survivors witnessed violence, 57% witnessed killing with a machete, 31% of female survivors suffered rape or sexual assault and 90% believed surviving was a miracle (Republic of Rwanda Ministry of Health, 2012).

While no large-scale studies on the prevalence of mental disorders in Rwanda were conducted in the years directly following the genocide, a 2009 study found that 26.1% of the Rwandan population suffered from PTSD and 22.7% suffered from depression, and depression comorbid with PTSD was measured at 17.8% (Munyandamutsa et al., 2012, p. 4). These numbers are extraordinarily high when compared to global rates of mental illness: the Institute for Health Metrics and Evaluations reported that the worldwide prevalence of major depression in 2017 was 3.4%, while anxiety disorders (including PTSD) was 3.8% (Dattani et al., 2021).

Theoretical framework: understanding implementation through a complexity lens

Policies, such as Rwanda’s Mental Health Policy, are created by government in response to the perceived needs of the country and its citizens. Following policy formulation and policy adoption comes the crucial step of implementation. Complexity theory, a branch of systems theory, provides a lens that aids ‘understanding of the mechanisms through which unpredictable, unknowable and emergent change happens’ (Ramalingam and Jones, 2008, p. 61). While traditional systems theory tends to assume that systems have dominant rules, clear feedback loops and a control system, ultimately leading to predictable results, complexity theory emphasizes that systems often defy ‘calculated equilibrium’ (Ramalingam and Jones, 2008, p. 5).

Complex systems are characterized by interconnected and interdependent elements and dimensions. Within these elements, feedback processes shape how change happens, resulting in emergence, whereby the behaviour of the system changes from the interaction of the parts (Ramalingam and Jones, 2008). Complexity increases with uncertainty, with much of the information required to inform action only emerging during the implementation process (Hummelbrunner and Jones, 2013). According to complexity theory, planning must be participatory and adaptive to new developments (Hummelbrunner and Jones, 2013, p. 4). Robert Chambers (as cited in Ramalingam and Jones, 2008, p. 6) explained that to manage complex systems ‘the key is to minimize central controls’ and to ‘use rules which promote and permit complex, diverse and locally fitting behaviour’.

Complexity theory provides an ideal lens through which to understand the above research. The mental health policy in Rwanda is surrounded by uncertainty: its creation was based on little to no data (there was none available at the time), and while its interventions may be based on research, they are not based on robust evidence, as few post-conflict countries have implemented mental health policies. Additionally, there are many macro-level challenges in the Rwandan setting that increase complexity including the low-income, post-genocide and post-conflict status of the country, stigma surrounding mental illness and the use of mental health services as well as the authoritarian nature of the current regime. To further increase complexity, the policy is implemented by a variety of actors, governmental and nongovernmental, all of whom have different relationships with each other and to the policy and different visions for successful implementation.

Methods

Study setting

The findings are based on 30 interviews conducted with stakeholders in Rwanda in 2019. Interviews took place in two locations: Kigali and Ngoma. Kigali was selected as it is the capital of the country, and the Rwandan Ministry of Health (MoH) and the Rwanda Biomedical Centre are located here as well as many prominent nongovernmental organizations (NGOs) working in the domain. Ngoma, located in Eastern Province, was selected as it is a rural and more neglected district. The City of Kigali and Rwanda’s Eastern Province have similar rates of mental disorders among genocide survivors (Rwanda Mental Health Survey, 2018), yet services are not equally distributed, with the majority located in the capital. Conducting interviews in these two locations provided insight into how the policy is being implemented in contrasting regions.

Design and demographics

Participants were selected using purposive sampling and included government officials, NGO representatives, service providers and academics. Two sets of 10 open-ended questions were developed: one for implementers in government institutions and a second for remaining participants. Twenty-one interviews took place in Kigali and nine took place in Ngoma. Eighteen participants were female, and 12 were male. Five were implementers in government institutions; 10 were service providers in hospitals, health centres or private practices; 2 were academics and the remaining 13 were representatives from NGOs, both local and international. The interviews were conducted in English, French and Kinyarwanda, with those in Kinyarwanda taking place with the assistance of an interpreter. These interviews were complimented by secondary literature as well as primary sources, including Rwanda’s Mental Health Policy, official government documents and NGO reports.

Analysis

The interviews were analysed through thematic analysis in order to identify common themes and patterns in responses and to map out the implementation process. The initial codes used to analyse the interviews were predetermined based on the research questions and included (1) context, (2) process, (3) challenges/gaps and (4) successes/best practices. The challenges were analysed further with inductively developed codes.

Results

Context

Prior to the genocide, mental health services in Rwanda were scarce and mental health in general was not prioritized by the country. One exception was Ndera Psychiatric Hospital, an institution founded on the outskirts of Kigali in 1968 by a religious organization in response to requests by the government of Rwanda and the local Catholic Church to release psychiatric patients from prisons (Stockman, 2018; Careas Ndera Hospital, 2020). The hospital expanded over time, and efforts began to further develop and decentralize care in Rwanda. However, the overall mental health infrastructure remained minimal for a population of nearly 5 million people and mental illness continued to be highly stigmatized. As a result, the mentally ill faced neglect, harassment and discrimination. When the genocide began, Ndera Psychiatric Hospital was not immune to attacks: the building was destroyed, equipment pillaged and records disappeared, and the personnel, patients and locals seeking refuge in the hospital were massacred (Stockman, 2018; Careas Ndera Hospital, 2020). The mental health sector, which was very small to begin with, was destroyed.

The state introduced a national mental health policy in 1995, approximately 1 year following the conclusion of the genocide and civil war. Information regarding the 1995 version of the policy is scarce, with no one from the MoH able to locate a copy when asked. There is also little information regarding the initial conception and development of the policy. According to one stakeholder, civil society, especially IBUKA, the umbrella association of genocide survivor organizations, was key in pushing for a mental health policy (field notes, April 2019). Although this information could not be corroborated by others, it is included due to the important position of the informant.

Ndera Psychiatric Hospital was reopened in 1996 with Swiss and Belgian aid. However, this time, thanks to the policy, rather than being the sole institution to offer mental health care, services became decentralized and generalists throughout the country were trained to respond to mental health issues. The policy was revised in 2011, and a new version was published in 2012 to respond to the ‘new challenges, new environment, [and] the new questions raised from the community’ (interview, March 2019). A new branch of the MoH, the Rwanda Biomedical Centre, became the implementing body of the policy, led by its Mental Health Division. Policymakers consulted various stakeholders in the drafting of the revision, especially academics, but also some local associations, community health workers and traditional healers (field notes, April 2019, interview, March 2019).

The revised policy includes the general objective to ‘promote quality mental health care that aims at reducing morbidity in mental health, appropriate to the context and is accessible to the community’ (Rwanda Mental Health Policy, p. 6). It also contains specific objectives, including to ‘promote multi-sectoral collaboration’ and ‘promote community care in mental health’.¹ Lastly, it includes strategies for intervention in 10 different fields. These fields are (1) the decentralization of services, (2) insurance coverage, (3) human resources development, (4) sensitization, (5) legislation, (6) research, (7) psychopharmacological treatment, (8) epilepsy treatment, (9) prevention and treatment of substance abuse and (10) mental health care for children and teenagers.

Process

This section will describe the implementation process based on the general objective of the policy as well as the two specific objectives listed above. These two specific objectives have been selected as themes to understand the process as they represent approaches guiding implementation, whereas the other specific objectives are concrete strategies and interventions to be implemented.

Accessible, appropriate and quality mental health care

In order to increase access, the policy relies on strategies of integration and decentralization of mental health care into the primary health care system. To achieve integration, the government started training nonspecialists in hospitals and health centres to treat mental health issues following the genocide. Some medical doctors were also sent abroad to study, with a focus on psychiatry. At the time of research, community health workers were being trained to ensure mental health care is available at the community level. To ensure sustainability and quality of human resources, various post-secondary programmes have been established, including the Department of Clinical Psychology at the University of Rwanda in 2014. Multiple NGOs have also created training programmes for counsellors and mental health workers.

In tandem, decentralization is implemented through a referral system. In this system, patients move up and down between various levels of care, starting with the community health worker, then the community health centre, followed by the district hospital, and finally, the reference hospital. Different services and medications are available at each level, with only the most acute and complex cases reaching the top level. As a result of these strategies of integration and decentralization, nearly all health institutions in Rwanda offer mental health care, and the large majority of community health workers are trained in mental health care (80% according to 2019 interview with former Minister of Health, Diane Gashumba).

Accessibility is further promoted through increased affordability of care, achieved through the government’s modification of Mutuelle de Santé—the country-wide, community-based health insurance plan—to increase mental health care coverage. For those enrolled, coverage is available for all government-funded mental health services. There were, however, discrepancies in answers regarding the extent of coverage. In addition to government-funded care, numerous NGOs contribute to the policy’s goal of equitable access by offering mental health services and programmes including therapy and counselling, cooperatives for the mentally ill and community-based healing programmes designed to promote societal cohesion and reconciliation. There are also a small number of private practices offering Western-based talking therapy.

To ensure utilization of services, the government and NGOs alike have engaged in efforts to sensitize the population and reduce stigma surrounding mental illness. Examples from the government side, led by the Mental Health Division, include educational sessions with district, community and religious leaders, and high-level authorities, weekly radio shows, e-pamphlets and the annual celebration of World Mental Health Day. On the NGO side, some activities are specifically directed towards education and the reduction of stigma through advocacy work, but overall, sensitization is primarily a by-product of their other community-based initiatives.

Multi-sectoral collaboration

To promote multi-sectoral collaboration, the Mental Health Division established ‘coordination meetings’ with organizations working in the domain to discuss implementation of the policy.² The division also confirmed that they previously attempted to work with traditional healers through training and education so that healers could advise their patients to consult medical clinics. However, implementers shared that due to challenges, this work has been discontinued. The division also plays a large role across sectors in the preparation for trauma response during the annual genocide commemoration, leading the planning for trauma support for the annual ceremony and training mental health workers across organizations to respond to commemoration-specific trauma.

Community care

The main strategy undertaken by the government to promote community care has arguably been the training of community health workers, as these workers can assist patients close to home, or refer them to institutions when necessary. In both Kigali and Ngoma, clinical workers also conduct field visits where they administer medication in the community, or if necessary, bring community members to clinics for inpatient care. However, a large portion of the community-based work is currently carried out by NGOs in efforts separate from the government. These organizations offer community-based mental health care programmes targeting genocide survivors and perpetrators alike, as well as other groups including youth suffering from intergenerational trauma, refugees and the general population.

Stakeholder views on successes, challenges and gaps

Successes

Participants viewed most implementation strategies positively, especially decentralization and the resulting expanded accessibility of mental health services. Many highlighted how decentralization has led to every hospital in the country having a mental health unit and nearly all community health centres providing mental health care. Participants explained how this prevents overburdening reference hospitals, as less complicated cases can be treated at lower levels, while simultaneously easing the burden of patients who previously had to travel tremendous distances to receive care. Others commented on how decentralization was not exclusive to services and practitioners but also included the decentralization of available medication, which they also viewed positively. Further, participants were pleased that decentralization went down to the level of community health worker, stating that this promoted community-based care and expanded access to services, even in rural areas.

In addition to decentralization and integration, participants also pointed to the existence of the clinical psychology programme at the University of Rwanda and the overall increase in the number of trained professionals in the country as a success of the policy and its implementation. Various government officials and service providers also mentioned increased mental health service consultations as a huge success, viewing it as evidence that people were seeking care and accessing services rather than struggling alone.

Others highlighted that although it remained a significant challenge, they thought stigma had decreased as a result of the policy. They explained that Rwanda had made notable advancements since the pre-genocide years when people suffering from mental illness were outcasted, chained or jailed. Participants also thought there was more awareness among the general population of the available mental health services and where to seek care.

Preparation for trauma response during the annual genocide commemoration was also highly regarded as a successful practice, with a number of participants mentioning how the government, NGOs and private organizations collaborated well during this period. NGOs and private organizations pointed to multiple good practices associated with the provision of care during commemoration, including training provided by the government to their organizations. Another area mentioned by some participants as a good example of multi-sectoral collaboration was the ‘coordination meetings’ where government and NGOs discussed implementation.

Lastly, many participants raised the Rwanda 2018 Mental Health Survey, a national epidemiological study, led by the Rwanda Biomedical Centre with 22 stakeholders, as a success of policy implementation that will allow implementers to make evidence-based decisions.

Overall, participants were extremely grateful that a policy was in place and that there was national will to implement it, especially due to Rwanda’s post-genocide status and the prevalence of mental illness in the country. This was true even for participants who were highly critical of the implementation thus far. As one NGO representative shared: ‘I think the policy implementation has actually opened a flood gate, but in a good way, because it has helped to unearth many issues, many areas that we didn’t think about…’ (interview, 2019). The following section will delve into those issues.

Challenges/Gaps

Institutionalized care

The largest gap raised by participants was that mental health care in Rwanda is institutionalized rather than community and family-based. This critique came primarily from academics, psychologists and NGO representatives. These participants explained that rather than incorporating the community in the healing process, people suffering from mental illness typically receive individualized treatment in hospitals and health centres. Participants expressed that this approach is a form of crisis management relying heavily on medication rather than holistic healing. In addition, participants from various sectors explained that Rwanda only has access to first generation anti-psychotics, which do not always provide the best patient outcomes.

Participants agreed that hospitalizations and medication are necessary in extreme cases but argued that often alternative approaches, especially therapy, needed to be considered first. As one professor explained, ‘they haven’t understood how to include psychology in the policy… Things like [the] prescription of pills is seen as a cure’ (interview, April 2019). Another participant stated: ‘we’re coming from a very institutionalized mental health practice—we have psychiatric hospitals where you have these rooms and injections, psychiatrists… that’s like the European old way of mental health care’ (interview, March 2019). Overall, participants were adamant that the policy would not succeed if it did not adapt to incorporate the family and the community in the healing process. They emphasized that Rwanda is a community-based society and that ‘the policies that are in place are not catered in a traditional way to help local people’ (interview, April 2019). As another professor explained: ‘Mental health is not in hospitals. It’s in local communities. So if policymakers think that mental health is in hospitals, there will be problems If they don’t come down here in the communities to tackle those problems at their roots, there will be problems’ (interview, March 2019). This was a central theme in many interviews, with academics, psychologists and NGO representatives blaming this gap both on the contents of the policy and its implementation. In contrast, many participants working in medical institutions and within the government expressed that they did not have access to a sufficient supply of medication to treat patients.

Top-down implementation

Despite the policy containing the objective to increase multi-sectoral collaboration, a common challenge raised by many nongovernmental participants was that implementation was top-down. Many expressed that they were working in silos and highlighted a lack of collaboration among government implementers and those on the ground level. The following sentiment expressed by one participant seemed to echo what many others were explaining: ‘We’ve never run into any conflict with them, and we’ve never worked very closely’ (interview, March 2019). Stakeholders pointed to lack of opportunities to engage with the government on the policy and felt they were not consulted on its implementation, despite having valuable experience.

Many organizations and service providers simply wanted to be more involved in the process and to have their research, experience and opinions heard. Some participants mentioned the introduction of ‘coordination meetings’ between government and NGOs as a positive step towards more horizontal leadership. However, representatives from other organizations said that although they had heard about these meetings, they had never been invited. Government-level implementers responded to this by stating the meetings were open to everyone. Despite this, information about the meetings did not appear to be publicly available. Even members of organizations that attended the meetings or reported collaborating with the government still insisted that the government set the priorities, and the organizations followed. When asked how the next policy revision could best respond to the needs of their organizations, many simply asked to be involved. They stated that academics and researchers were often consulted, but the actual implementers working on the ground were left out of the process.

Stigma

Stigma was raised by nearly all participants as a primary implementation challenge. Although many participants felt that stigma had started to decrease as a result of the policy and that awareness around trauma and mental health had increased since the genocide, they still viewed it as the largest barrier. They explained that mental illness is still not widely understood as a neurological disorder in Rwanda and continues to be associated with possession, demons and witchcraft. Many stated that beyond paranormal beliefs, stigma around mental health also originates from the local culture, and that sharing sufferance or hardships is often equated to weakness in Rwanda. Various interviewees used the expression ‘culture of silence’ to explain the Rwandan approach to sharing personal problems. Other participants pointed to a lack of trust within the community, identifying the difficulty in consulting mental health specialists because ‘people don’t believe that their story won’t be on the street before they reach home’ (interview, March 2019).

Service providers shared the difficulties of getting patients and their families to accept treatment, and how those who did often had trouble reintegrating into society, despite successful recoveries. They explained how this has led the same patients to return numerous times, as social and professional exclusion post-recovery leads to relapses. Likewise, participants spoke about how individuals who had experienced mental health issues are automatically seen as ‘persona non grata’ (interview, March 2019), demonstrating how stigma persists even when symptoms of mental illness are managed or are no longer present. This discourages those suffering from utilizing services despite the possible benefits, as they do not wish to be stigmatized or outcasted from their communities. As a result, patients go untreated or consult traditional healers or religious healers instead of clinical services (interviews, March 2019, Rwanda Mental Health Survey, 2018), many of whom do not have the necessary clinical training to treat such issues.

Lack of financial resources

Many participants pointed to a lack of financial resources as a challenge, explaining how infectious diseases, due to high prevalence, morbidity and mortality, have been prioritized financially over noncommunicable diseases. An NGO representative spoke of the same issue among donors: ‘they say that mental health doesn’t kill [a] person. But if someone suffer[s] from physical disease, they respond directly. But about mental health? Oh, can wait. Everyone still thinks that mental health can wait’ (interview, March 2019).

Lack of financial resources was identified as a challenge at the government level and at the hospital and patient level, with this challenge being especially prominent in Ngoma. Participants explained that patients have difficulty covering the expenses of mental health care and that the burden often falls on the family. In cases where the family cannot afford to pay for the treatment or the family has abandoned the patient, the burden falls on the hospital or the district. As one participant stated: ‘the first problem we have in the community is mental health cases require insurance…’ (interview, April 2019). While Rwanda has made remarkable strides in increasing the scope of mental health care coverage, there are still Rwandans not enrolled in the community-based insurance scheme. Service providers also raised the issue of mentally ill patients who have been living on the streets without any form of identification, or patients who do not know who they are, making it virtually impossible to access coverage even if they are enrolled. And although government-level implementers insisted that mental health care was 100% covered for those enrolled, service providers challenged this notion, emphasizing how medication and counselling are covered, but hospital fees such as hygiene products, food or clothes, often required by mental health inpatients, are not.

Lack of human resources

Despite the increase of available mental health professionals in Rwanda as a result of generalist training and psychology-based programmes, some stated that there are still not enough specialists in the country and that not all providers are properly trained. Others, mainly those working outside of the government, offered a different story, explaining that there is an abundance of well-trained professionals, but they are unemployed. Some attributed this to a lack of will from the university to advocate for their employment and a lack of initiative from the government to recruit them. The explanation for this issue, however, remains unclear. Participants, overall, and especially those in Ngoma, did agree that most available services and providers are concentrated within the capital and that it is difficult to receive specialized care beyond Kigali.

Discussion

As mentioned in the introduction, there are several macro-level challenges in Rwanda that increase the complexity of implementing its national mental health policy, namely the post-conflict/post-genocide and low-income status of the country, mental health-related stigma and the authoritarian nature of the current regime. Using a complex system lens, this section will uncover the intersections between these macro-level challenges and the micro-level challenges revealed through this research. It will also identify the resulting emergent behaviour from actors in their attempts to manage these challenges and conclude with suggestions for managing this complex system.

Post-conflict/post-genocide and low-income status

Rwanda was a low-income country prior to the civil war and genocide, with the violence exasperating the situation. The country did not have the resources to build a mental health system in the aftermath of the civil war and genocide and instead improvised to respond to the mental health emergency by utilizing available resources and integrating mental health care into the already existing primary health care system. This response is the first instance where we witness emergent behaviour in the face of complexity.

As policy implementation continues, complex challenges continue to arise: many participants referenced a lack of trust in Rwandan society, despite those same participants continually referring to Rwanda as a community-based society. Although not specified by all participants, this may be attributed to mistrust perpetuated by the violence: Ingelaere and Verpoorten (2020) found that although it has decreased over time, the genocide resulted in extensive intra-ethnic mistrust among Rwandans. This lack of trust is heightened by stigma, as people fear the societal consequences of sharing their mental health status.

Implementers at all levels have responded to this by trying to restore trust in the community through community building and community-based care. The Mental Health Division, for example, has attempted to bring mental health care into the community via the training of community health workers, which is not stipulated in the policy. NGOs have likewise responded by prioritizing community-based healing programmes and advocating for community and family-based care. In this way, implementers have attempted to heal post-conflict societal wounds and maximize limited resources, as people can be treated by nonspecialists and in groups.

Stigma

Although one may not expect stigma around mental illness and mental health service utilization to be high in a society that has widespread mental health concerns among its population as a result of shared traumatic events, i.e. war and genocide, stigma remains a challenge for mental health policy implementation in Rwanda. This is consistent with previous research on mental health policies in post-conflict countries (Stockwell et al., 2005; De Vries and Klazinga, 2006). In Rwanda, stigma has hindered the consultation of mental health services, even though they have become increasingly available and accessible. As a result, many conditions worsen and are not treated in a timely manner. Those who are treated do not always fare better, as some relapse due to post-recovery exclusion and stigmatization.

Implementers have attempted to mitigate this by conducting sensitization sessions/campaigns with religious healers, traditional healers and the general population but admit that success has varied. As a result, patients and families act as navigators in a system composed of various clinical and nonclinical access points that are often not coordinated. Further, many of these nonclinical resources are not well suited to treat mental health issues and may even exacerbate mental health conditions. All of these scenarios add financial strain to a system that already has limited resources as patients require more treatment to recover when not treated in a timely matter or are treated multiple times. This scenario provides insight into the intersections of the challenges, whereby the emerging behaviour of patients as a result of stigma and lack of community trust exacerbates the financial challenges already present in the system.

Authoritarian governance

Scholars have referred to Rwanda as a ‘developmental regime’, defined as ‘nominally democratic governments which provide significant public works and services while exerting control over nearly every facet of society’ (Matfess, 2015). Although stating that it should not be viewed as a desirable method, others have attributed Rwanda’s success in creating an efficient health care system, including the high enrolment in community-based health insurance, to the authoritarian nature of the regime (Chemouni, 2018; Yarlagadda, 2022). Regarding its mental health policy, one might expect its reliance on decentralization to result in dispersed power, but decentralization has been criticized in Rwanda as a means of increasing central control and limiting local autonomy and decision-making (Löffler, 2017). This is due to the Rwandan government’s history of using decentralization to consolidate power through a system of local governments that respond to heavy-handed control, therefore expanding the reach of the government to ‘the remotest hills of the country’ (Löffler, 2017, p. 12).

The implementation of the mental health policy fits this description, as directions originate from the top and travel to the lowest levels, with little room for adaptation or feedback. In this way, the mental health policy has been efficiently implemented. However, because ideas from lower levels are not travelling to the top, implementation does not always meet the needs at the ground level. Even when activities, such as coordination meetings, take place, they are not always inclusive, and directions still flow unidirectionally.

This has led to emergent behaviour, whereby nongovernmental actors are offering services and programmes that they deem more community-based and therefore more appropriate in the Rwandan context. In some respects, this has been positive, as these organizations stated that they were filling a gap of implementation. However, the lack of coordination and the siloed environment resulting from this has also led to various and competing access points for care, and care that is largely individualized and institutionalized on the government side. It has also led to information regarding some of the bottlenecks of implementation, such as challenges regarding insurance coverage, not reaching the top.

Managing complexity

This section argues that many of the challenges and gaps in the policy’s implementation could be better addressed by shifting to a collaborative, adaptive and horizontal implementation approach. Complexity theory suggests that implementers learn and be adaptive to new developments throughout the process. The best source of knowledge, which the Rwandan government has arguably not sufficiently utilized, is the people working on the ground. These individuals have a wealth of knowledge based on their unique experiences and an awareness that goes beyond reports and statistics. There may be ways to address the various challenges raised in this research, but this can only take place if implementers at the highest levels are aware of these challenges and are willing to accept ideas and suggestions from those experiencing them first-hand.

In an ideal situation, allowing more diverse opinions into the discussion would broaden decision-making power by promoting participatory decision-making. However, this is likely an unrealistic and unattainable goal in an authoritarian country. This is a key limitation to mental health policy implementation in Rwanda, as navigating policy implementation in the face of complexity requires implementing agencies to facilitate self-organization and decentralize decision-making (Jones, 2011; Hummelbrunner and Jones, 2013). Although some efforts have been made by implementers to be collaborative, it is likely that organizational culture in the civil service is influenced by authoritarian governance, impeding even the best efforts. The gaps in implementation as raised through this research reveal the resulting disadvantages of concentrated power and showcase how increased control does not always produce better results.

Conclusion

Mental health policies are essential to any country, and especially in a post-conflict or post-genocide country. War and genocide can cause extreme trauma for local populations and destroy the fabric of societies. This can result in debilitating mental health issues for both current and future generations. Rwanda has been a trailblazer for the African continent through its recognition of the importance of mental health and its continued implementation of a national mental health policy. Despite its challenges, it has seen many successes, especially in the exponential increase in availability, accessibility and affordability of mental health services for the general population.

This article represents one of the few studies to look at the implementation of mental health policies in post-conflict countries and the first to do so in Rwanda. While this research did not measure the success of Rwanda’s Mental Health Policy, it has highlighted the complex process of its implementation while providing an inside look at the dynamics, thoughts and opinions of stakeholders. Specifically, the findings have demonstrated that it is possible to prioritize mental health in complex settings, even with scarce resources. By revealing the challenges and gaps, it has also demonstrated the limitations of top-down implementation and the need for collaboration and inclusion when managing complex systems.

Finally, this research provided insight into mental health policy implementation in general, a subject rarely studied. This is important not only because of the prevalence of mental illness in Rwanda but because of the prevalence around the world. Mental illness can be debilitating, and the services available worldwide do not match the need based on the data and estimations, especially in post-conflict countries. Looking at what Rwanda has done in this field and continuing to research its progress, challenges and successes will provide examples of what does and does not work when implementing a mental health policy. Having more knowledge on this subject will hopefully encourage other countries to develop and implement mental health policies, therefore bridging the global gap in the availability, accessibility and quality of mental health care and treatment.

Data availability

The data underlying this article cannot be shared publicly due to ethical concerns, namely to protect the privacy of the participants.

Acknowledgements

The author would like to thank Marie-Eve Desrosiers for her support and mentorship throughout this project. She would also like to thank all of the individuals in Rwanda who supported this research as well as all of the participants for sharing their thoughts, experiences and time.

Reflexivity statement

This manuscript is written by a sole author from a high-income country. The author has studied Rwandan history and politics as part of her formal education and has experience working in policy implementation, including health policy implementation, in her home country of Canada. The manuscript does not include low- and middle-income country authors due to it being based on a thesis where the requirements included sole authorship. The author recognizes this as a limitation to the study.

Ethics

Ethical approval for the study was granted by the University of Ottawa (S-12-18-1331) and the Rwanda National Ethics Committee (0066/RNEC/2019).

Conflict of interest statement

None declared.

Footnotes

1.

Other specific objectives include the integration of mental health care in all health structures, creation of mental health legislation, providing quality care via well-trained human resources, initiating a strategy of intervention against substance abuse, adopting a policy and care for trauma, initiating a strategy of intervention for epilepsy and creating a system of care and prevention for psychosocial problems among youth.

2.

It is unclear if these meetings have continued during the global coronavirus disease 2019 (COVID-19) pandemic.

Author notes

Please note that this paper does not have an author from the region of study due to the research being conducted for the purpose of a master’s thesis paper. As per the requirements of a thesis paper in the master’s degree programme at the University of Ottawa, the student was the sole author of the thesis, on which the current article is based on. The author values the importance of local partnerships when conducting research and did work with local professionals and researchers, but no other individual met the criteria for authorship. These individuals are also not mentioned by name in the acknowledgements section, due to the sensitive nature of the research and the contents of the manuscript. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views of other research contributors.