A decade of collaboration: developing a community-based mental health service in Tanzania with CNWL NHS Foundation Trust and Mirembe National Mental Health Hospital

We recently had the opportunity to speak with Chris Bumstead, the CNWL International Healthcare Partnerships programme coordinator, who has been involved in the partnership between Central & North West London NHS Foundation Trust and Mirembe National Mental Health Hospital in Tanzania since 2011.

1. Tell us about your background and any history of volunteering in global health work. 

I've been involved with the partnership between Central & North West London NHS Foundation Trust and Mirembe National Mental Health Hospital in Tanzania for over a decade. I started as a volunteer in 2011 and had the privilege of visiting Mirembe six times between 2011 and 2014 to take part in our funded projects. In 2015, I was honored to be appointed as the Coordinator of the CNWL International Healthcare Partnerships program, which has since expanded to include two additional partnerships in Zimbabwe and one more in The Gambia.

Since taking on this role, I've made 10 visits to Mirembe and worked closely with our partners to improve mental health care services in Tanzania. While I haven't had the opportunity to visit our other partnerships in Zimbabwe and The Gambia yet, I did have the pleasure of visiting Tanka Tanka Hospital in The Gambia in 2011 before it became one of our partners in 2020.

2. Tell us more about your health partnership. 

Since 2010, we have been involved in a long-standing partnership with Mirembe Hospital, which has been instrumental in receiving grants from organizations such as THET,  DfID (as it then was), and more recently, the HEE Global Placement Bursary. These grants have helped us to improve our working relationship and advance our projects. We are grateful for the funding support that has enabled us to work on several projects, including the Therapeutic Management of Violence and Aggression (2010-2013), Substance Use Service Development (2014-2017), and Mental Health & Substance Use Training for unqualified staff and Peer Support Workers, along with Management and Leadership support (2018). Our latest project under the GPB grant (2023) is focused on the development of a community-based mental health and substance use service. This initiative has been in the works for the past 8-9 years and we are excited to see it come to fruition.

3. Why were you interested in taking part in a global health partnership? 

My interest in global health partnerships was sparked during a trip to The Gambia as part of my work with a UK-based charity that supports deaf children's education (www.kadect.org). While there, I visited Tanka Tanka Hospital, the only mental health facility in the country, to explore potential connections with the Tanzania partnership I had learned about through CNWL news bulletins.

Upon returning to London, I approached the Tanzania Link team to explore collaboration opportunities, but was initially told that Mirembe had plenty of ongoing projects. Undeterred, I joined the Tanzania Link team myself and offered my background in occupational therapy, senior management, and patient involvement to the cause. As Head of Patient & Public Involvement, I was able to make frequent visits to Tanzania while effectively managing my workload.

Since then, I have remained involved with the partnership and even took on the part-time role of International Partnerships Coordinator following my early retirement in 2014.

4. What prompted you to carry out this specific project? 

The idea of creating a community-based mental health service through Mirembe Hospital has been in discussion for almost a decade, with the hope of addressing multiple challenges. Firstly, unnecessary admissions and re-admissions of patients to the hospital can be reduced, which would lessen the burden on the limited hospital budget and ease the heavily overloaded bed occupancy. Secondly, community care for patients is preferred, allowing them to retain contact with their family and community while continuing their rehabilitation process. Thirdly, a community service can assist district hospitals in treating their patients locally, avoiding unnecessary costs for patients and their families to travel to Mirembe for basic follow-up. Additionally, having a community service could help overcome the stigma around mental health and substance use by building stronger connections with local communities, elders, and traditional healers.

When the opportunity arose through the Global Placement Bursary, we knew it was the perfect chance to get the ball rolling on this project. We wanted to start the initial training with staff at Mirembe, identify and prepare a small team of multi-disciplinary staff to take on the responsibility for training colleagues, and spearhead the work needed to bring the project to life, including training staff at district hospitals. The bursary allowed us to send two volunteers from CNWL for a month, but the scope of the project was so significant that I decided to accompany them using my own funds to assist in the training and follow through on the work afterward.

After the volunteers returned to London, I stayed on at Mirembe for a further seven weeks, working with small groups of "Champions" to address the details of setting up the new service, developing new documentation, establishing referral criteria and processes, designing operational practices, and creating a comprehensive training program. We also drafted budgets for the new service, re-established a 24/7 telephone help and triage line, and met with the Head of Mental Health and Substance Use, the Commissioner for Non-Communicable Diseases at the Ministry of Health, and the Mirembe Senior Management Team. With everyone's combined efforts, we are confident that this project will make a significant impact in providing better care and treatment for patients with mental health and substance use disorders in the region.

5. Please detail the impact of your work on the health facility/workers involved.  

We may not know the full impact of our work just yet, but we have made a strong start in establishing a team of 24 dedicated staff who are committed to taking on new responsibilities in the community-based mental health service. These staff members will work one day per week each in the new team and collect pre-project data, such as hospital admissions and re-admissions, time between admissions, patient views and expectations, adoption of new documentation, and training provided. This data will be used in an ongoing monitoring and evaluation program, with the hope of publishing a research paper in the future.

Feedback from the staff who received training through this project has been positive, with many indicating that their knowledge and confidence have grown, making them better equipped to work in the community. The new service will initially launch as a pilot in the Dodoma Region, which is roughly the size of England. Our long-term goal is to expand the service to the rest of the country, pending additional resources.

To support the team, CNWL will provide mentoring groups and online training events. We also hope to visit Mirembe again in 2023/24 to continue supporting the team and monitoring the progress of the project. We are excited about the possibilities this project holds for improving mental health care in Tanzania, and we look forward to seeing the impact of our work in the future.

Quotes from Volunteers 

“This was a really good opportunity for me to work in an international health setting (outside of the NHS), which is the first time that I have ever done this.“  

“This experience gave me exposure to different understandings of mental health, its aetiology and useful strategies for working with patients. For example, it is very common for people in Tanzania to attend witch-doctors/ healers when they experience a mental health problem. I learned about how mental health professionals have met with healers to try and work with them/ educate them. This was a very inspiring example of ways that professionals can work together with traditional cultures/ customs to get the best outcomes for their service users.“  

“Supporting the staff to establish a community mental health team taught me a lot about operational issues and strategy. While I have worked in management, I have never been part of the genesis of a team myself. “ 

This experience taught me to think creatively with the resources available and practically in terms of what would be required operationally. This also developed my skills around problem-solving and troubleshooting in partnership with my colleagues in Tanzania. “ 

“I also developed my skills around creating training materials and delivering training. This was a new experience for me working with trainees from Tanzania and for whom English was not their first language. This challenged me to adapt the training material accordingly and to be very receptive to the trainees’ experiences/ feedback.“   

“Learning how to provide good quality of care with limited resources has helped me be more creative and efficient. I believe this could help me utilise resources better in the UK and it will help the way I design interventions. Moreover, the teaching style adopted there will help me improve any future training I provide in the UK.” 

Quotes from Mirembe colleagues 

“The project will be very beneficial to us if we think of improving interventions at the district level, so that people who currently go to traditional healers and arrive late for proper mental health treatment can be seen earlier. Some of our patients get involved in crime because of their mental health or substance use problems because they are not being treated. Early intervention in the community will be very productive, and it will be better for the patients if they don’t have to come to Mirembe and pay for transport when they can be followed up in the community.” Pasinai Kivuyo – Hospital Matron 

“I found it very useful to learn how to assess patients based on their experiences of trauma in their life and how their behaviour and mental health is affected by that trauma. I was able to learn a lot about working in the community because through my training and work at Mirembe I have not been used to doing that. Training more staff using the packages we have developed will enable staff to know more about their patients and the patients will get a better quality of care because they will be referred appropriately to the right professionals. I think the Champions will be able to cope with the extra workload because as more staff are trained the work for everyone will be easier because we’ll be working as a team. “ Gertrude Anthony – Occupational Therapist 

“My expectations were met and exceeded. I thought it was going to be difficult because the volunteers were from a different continent and culture, but they were very adaptive. It was a good experience and we would like to work with them again. Through my training as a doctor we do not receive training on how to assess risk and develop care plans, but I can now include that in my practice and improve the care and management that I give to my patients. The main thing I learned was to put the patient at the centre of everything I do as a doctor. We now know that we have to listen to the patient and understand their experiences and what they can cope with. By using the training we have received through this project we can change the way in which we provide care and the whole of society will benefit.” Dr Naomi Mrina – Medical Doctor & Tanzania Link Lead