A nationwide evaluation study of the quality of care and respect of human rights in mental health facilities in Ghana: results from the World Health Organization QualityRights initiative

This is a mixed-methods convergent design study aimed to assess psychiatric facilities from different Ghanaian regions and provide evidence on the quality of care and respect of human rights in mental health services.

We conducted the study in seven different mental health facilities: Accra Psychiatric Hospital, Ankaful Psychiatric Hospital, Eastern Regional Hospital, Ho Teaching Hospital, Komfo Anokye Hospital, Sunyani Regional Hospital, and Korle Bu Teaching Hospital (psychiatric facility). These mental health facilities are located in different Ghanaian regions and were selected to provide a representative picture of the quality of care and respect of human rights in psychiatric services throughout the country.

In each facility, the assessment was conducted by independent visiting committees. Members of the visiting committees were selected from multidisciplinary backgrounds and also included 1 Human rights advocate from NGO, 2 service users, 5 Mental health advocates from NGO, 1 Psychiatrist, 2 Intellectual Disability Organization advocates, 1 Psychosocial Disability Organization advocate and 1 Researcher. A three-day training was organised in Accra for 34 participants (10 women, 24 men) to build their capacity on the evaluation of the quality of care and human rights respect in mental health facilities (using the WHO Quality Rights Toolkit). Thirteen visiting committees’ members were selected from the pool of participants based on their availability and personal background (to guarantee a broad range of expertise and skills). At least one service user was present in all the visits to the facilities. To ensure the committee was well-trained on the methodology for the assessment, there was a simulation exercise at the Pantang Psychiatric Hospital in Accra. The evaluation visits were planned in collaboration with the management staff in each facility. During the evaluation visits, the visiting committees carried out an observation of the facilities, the review of the documentation, and interviews with service users, their carers, and staff members. Visiting committee members collected both quantitative (e.g., data on length of stay at the hospital, number of users per ward, quantity of essential psychotropic medications) and qualitative data (e.g., photographs of the facilities’ physical environment, notes regarding the presence of policies and guidelines, notes regarding the information in medical files and nurses’ charts, notes based on the interviews including verbatim quotes by respondents). All the visiting committees’ members collected data through observation. The retired psychiatrist was assigned to carry out the documentation review because of his wealth of experience in direct mental health practice. The researcher was designated as rapporteur to collate notes and compile results while the rest of the trained visiting committee members collected data through interviews. In between the assessments, the coordinating team continued to organise virtual meetings through zoom to discuss challenges and feedback from the field for redress. Assessment reports were written for each of the facilities evaluated, with recommendations for improving the quality of care and respect of human rights.

The quality of care and respect of human rights in mental health facilities were assessed using the WHO QualityRights Toolkit [14]. This instrument is based on the modern human rights framework of the United Nations Convention on the Rights of Persons with Disabilities and includes five themes. Each theme focuses on a specific UN CRPD right: 1) The right to an adequate standard of living (Article 28); 2) The right to enjoyment of the highest attainable standard of physical and mental health (Article 25), 3) The right to exercise legal capacity and the right to personal liberty and security of person (Articles 12 and 14); 4) Freedom from torture or cruel, inhuman or degrading treatment or punishment and from exploitation, violence and abuse (Articles 15 and 16); and 5) The right to live independently and be included in the community (Article 19). The themes are organized into standards, which consist of different criteria (see the example in Fig. 1). The WHO QualityRights Toolkit has been previously used in several countries [16‐19], including Ghana [20]. Although the Toolkit has not been formally validated for use in Ghana, the members of the visiting committees checked its contents and adapted them to the local context (e.g., adding prompts relevant to Ghana in the interview instrument). The adapted WHO QualityRights Toolkit was pilot tested before the evaluations started, during a training simulation exercise at the Pantang Psychiatric Hospital in Accra.

The visiting committee members integrated qualitative and quantitative data using a mixed methods convergent design [21, 22]. First, in all the facilities assessed, they assigned a score to each theme, standard, and criterion using a mixed-method approach, based on 1) the data collected with the observation of the facility, the review of the documentation, and the interviews with service users, their carers, and staff and 2) extensive discussions among visiting committee members. During the discussions, the rapporteur presented the notes and photographs from the visits and the visiting committee members integrated with their own notes when needed. Each theme, standard and criterion was scored as follows: “Not initiated—N/I,” “Achievement initiated—A/I,” “Achieved partially—A/P” “Achieved in full—A/F”, or “Not applicable – N/A.” First, the visiting committee members evaluated criteria. Then, based on the scores at the criteria, a score was assigned to the corresponding standard. Finally, scores at the standards were used to assign a score at each theme. Using the ratings, provided by the visiting committees, for each standard, we calculated the total number of criteria (with corresponding percentages) that received the different scores (i.e., N/I, A/I, A/P, A/F, N/A) in all the facilities evaluated. These percentages were then presented in the form of bar charts reflecting the adherence to the rights represented by each theme. Finally, we analyzed the qualitative descriptions and justifications provided by the visiting committees in the reports to identify areas for improvement surrounding each of the five themes and provide recommendations. The same analytical method has been used for analyzing the data from evaluations carried out in other countries.

During each visit, the assessment team conducted an observation of the facility, a review of the documentation, and interviews with service users, their family members, friends, or caregivers, and staff members. Table 1 provides information on the number of staff members and service users in each facility, the number of interviews completed, and the length of the visits.

In regard to adherence to theme 1 (see Fig. 2), three of the mental health facilities evaluated had actively initiated changes to guarantee an adequate standard of living for service users, while the other four had partially met the standards of this theme.

Overall, most of the buildings were found suitable for use, but some of the wards were old and required structural renovations (e.g., for leaking roofs, cracks in the walls, electric wires exposed, broken windows, insufficient lighting, and absence of mosquitos’ nets). None of the mental health facilities was barrier-free for people with disabilities. In most hospitals, fire extinguishers were only available at a few vantage points, and, with some exceptions, both staff and service users were not well informed on fire safety protocols and other safety measures.

There were separate sleeping quarters for males and females in all psychiatric facilities, and the sleeping conditions of service users were generally comfortable. However, in some facilities, service users were not provided with clean mattresses and bedsheets. Furthermore, most of the sleeping wards did not have a designated place for changing clothes, and no provision was made for partitions or lockers to provide privacy to service users. Overall, washrooms and toilet facilities were found to be clean and functioning during the visits. However, bathrooms and toilets were in poor hygienic conditions in some wards and needed maintenance work (e.g., they were not cleaned regularly, toilets seats were spoilt, flushing handles were broken). The food was generally prepared under hygienic conditions, adequate, and in a sufficient quantity for the dietary needs of service users, although in some hospitals, service users had to buy their drinking water. All the facilities respected service users' right to use clothes of their choice.

Service users were allowed to receive visitors during scheduled visiting times. Generally, service users were permitted to use their own electronic gadgets (e.g., phones and laptops), although sometimes this right was restricted “depending on the service users’ condition” and “for fear such gadgets could be used to order illegal drugs into the hospital.” As a result, some service users were only allowed to use the ward phone, and their conversations were monitored by staff, so privacy was not fully respected.

The visiting committees found that the facilities’ building environment was, in general, not stimulating and conducive to interaction. Only in certain facilities, the layout of the wards promoted interaction among service users and staff, and service users could watch television or play ludo and other local board games such as oware for leisure activities.

Service users also had difficulties in remaining engaged in their communities' life and activities. In some hospitals, they were allowed to participate in activities outside the facility (but only if requested by their families).

Adherence to theme 2 (see Fig. 3) was partially achieved in two of the psychiatric facilities evaluated and initiated in the other five.

Overall, mental health services were available, publicly funded, and accessible to the general public. The admission protocols did not discriminate based on gender, race, religion, and ethnicity. However, some of the hospitals did not admit service users with physical disabilities and children or adolescents, and no referral policy was in place. In some facilities, users or their families were asked to make a financial commitment before treatment was provided. Furthermore, service users with higher economic resources had access to special wards and could pay for a better quality of care. In all facilities, service users were found to stay sometimes longer than their planned discharge because their families were not willing to welcome them back home, and they had no economic resources for living on their own.

All the facilities had a reasonable number of psychiatric nurses, but they lacked adequate numbers of psychiatrists, psychologists, occupational therapists, and social workers. The prevalent treatment approach was medical or pharmacological, while psychosocial support, occupational therapy or rehabilitation were often unavailable due to the scarcity of professionals trained to provide them. Furthermore, staff and service users reported that the facilities sometimes experienced shortages of medications due to a lack of funding. When psychotropic medications were not available, relatives were required to procure them from pharmacies operating outside the facilities.

There was an individual treatment plan for each service user in all the facilities, although this plan was generally not comprehensive and mainly based on mental health professionals' or family members' inputs. The visiting committees found that, although service users were sometimes informed about these plans, they were seldom asked to provide their input and express their preferences on treatment and recovery.

Overall, with some exceptions, staff had limited knowledge of international and national human rights standards, such as those included in the UN CRPD and the Mental Health Act. The visiting committees also found significant gaps in staff knowledge about community services and resources to promote independent living of service users and facilitate inclusion in the community. Staff facilitated linkages mostly between service users and other community psychiatric services or the Social Welfare Department. However, the Social Welfare Department was often unable to address service users' needs due to a lack of funding.

In some of the facilities assessed, service users undergo physical health examinations and screening for physical ailments upon entry. Some hospitals also provided basic general health services, although, for specialized general health care (e.g., surgery), service users were referred to other facilities.

In most of the facilities evaluated, health education and promotion were conducted to educate service users and, in some cases, visitors. For instance, following the outbreak of the COVID-19 pandemic, the hospitals embarked on constant education on the symptoms of the infection, the mode of transmission, how it can be acquired, safety protocols, and where to receive treatment. However, there was no evidence of service users being educated on any reproductive and family planning matters.

Six of the seven mental health facilities evaluated had taken at least initial steps toward fulfilling service users' right to legal capacity and personal liberty and security (see Fig. 4). Only one facility had not initiated changes toward fulfilling this theme.

None of the facilities prioritised service users' preferences regarding where to receive treatment or treatment options. Most of the time service users did not even know they had a right to make such decisions. Relatives usually provided informed consent regarding the type and place of treatment in consultation with the staff. Only when service users were deemed to be “stabilized” or in some instances where service users admitted themselves voluntarily into the facilities, was their informed consent sought.

Although legal avenues to appeal forced admission and treatment exist in Ghana, service users were not usually informed of this possibility. In some facilities, service users could nominate a support person to communicate their decisions, but this was not allowed in all instances. In none of the facilities were service users fully able to exercise their right to legal capacity.

Overall, all service users had personal medical files, and these were kept confidential from unauthorized access in all the facilities evaluated. However, service users had no access to their personal written information, and usually, they were not informed of their right to require access to their written records.

Five of the mental health facilities evaluated had taken initial steps toward fulfilling service users' rights to freedom from torture or cruel, inhuman, or degrading treatment or punishment and from exploitation, violence, and abuse (see Fig. 5). Only one facility had not initiated changes towards fulfilling this theme, while another facility had partially achieved this objective.

Service users told the visiting committees that they were generally treated with dignity and respect within the facilities. However, there were reports of verbal abuse by staff (e.g., yelling) and neglect was a common issue in all the facilities. There were also some reports of physical abuse as a form of punishment and control by staff. These violations were more common when staff had a heavy workload due to a lack of personnel.

Seclusion and chemical and physical restraints were found to be used in all the hospitals as a way of managing crises. The visiting committees found that sometimes these practices were also used to control “aggressive behaviors” or as a form of punishment for service users who tried to escape from the hospital or refused medication. In addition, alternative practices to seclusion or restraint (e.g., de-escalation techniques for potential crises) were rarely in place, and most of the staff had no training nor knowledge about these methods.

Not all facilities provided electroconvulsive therapy. The facilities providing electroconvulsive therapy required for the procedure either the informed consent of service users or, in line with guidelines contained in the Mental Health Act but not with the CRPD, approval of a mental health tribunal where “service users were unable to give consent”.

Medical and scientific research was conducted in some of the facilities evaluated, upon approval of the local Ethical Committee and with the informed consent of service users.

The visiting committee did not see any formal notice and information regarding the procedures for filing complaints by service users relating to abuse, violence, and neglect in the facilities evaluated. In some facilities, service users told the visiting committees that they were regularly asked verbally by nurses if they had any form of complaints and could express their concerns informally, but they were not aware of structured avenues to lodge formal complaints.

There is an independent body appointed by the government in Ghana, whose mandate is to monitor mental health facilities. However, the monitoring activities were found to be inadequate by the visiting committees.

In regard to theme 5 (see Fig. 6), only one out of the seven mental health facilities evaluated had initiated changes toward fulfilling service users' right to live independently and be included in the community.

In Ghana, opportunities for housing and access to financial resources for service users in their communities are limited. This makes it difficult for staff to support service users in this regard. Even though there is limited funding allocated by the central government for persons with disabilities at the district level (e.g., the Livelihood Empowerment Against Poverty program), these resources are not enough to support persons with mental health conditions in education, career development, and employment opportunities. Furthermore, the mental health facilities had no resources to link service users to the services operating at the community level.

Most of the facilities evaluated did not actively support service users to participate in political life, although staff helped service users register for elections in some wards. Only in a few wards were service users provided with information on public activities they could join outside the facility upon discharge.

Table 2 shows representative verbatim quotes from the interviews.