On January 26, 2009, Angella Nsimbi, now a mental health activist, stood under a mango tree between the Convalescent Ward and the Women’s Ward at Butabika National Referral Mental Hospital, holding her baby tightly to her chest.
“Anyone who has been to Butabika knows that tree. I looked at those women in green uniforms, saliva dripping from their mouths, hair cut off, and gripping the grills of the fencing. I kept saying to myself, ‘That is not me,’” says the 50-year-old mother of five.
A few days earlier, Nsimbi, a journalist at the time, had suffered a mental breakdown. The nine-month-old baby she was carrying was her fourth child.
“Mental health issues creep up on you. It happens progressively. I was raised in a polygamous family with a lot of pain and tension. My coping technique was to cover it up. I never talked about the issues. So, it was a combination; you are a wife, a young mother, a full-time working woman and you have emotional baggage. I just could not cope,” she says.
Nsimbi experienced a manic episode and was later diagnosed with bipolar affective disorder.
“I remember talking nonstop about the emotional pain. I had my baby tied to my back and I would not feed her the entire day. When my husband returned home in the evening, it was a struggle. It took three men to help me get into the house. They took the baby off my back and I was sedated. Three days later, my husband, his siblings, and a policeman took me to Butabika Hospital for a doctor’s appointment,” she explains.
Nsimbi took a seven-month break from work to recover. Fortunately, she worked as a freelancer and her sister was her supervisor.
Workplace triggers
For Nsimbi, the triggers were issues outside her workplace, while other employees have had to deal with mental health issues triggered by conditions in their workspaces. Before the Covid-19 pandemic, counselling was relatively a private matter that happened within the religious setting. However, the lockdowns and government policies on isolation brought to the fore the social and psychological problems employees were dealing with.
Derrick Kizza Mbuga, the executive director of Mental Health Uganda, says the upsurge helped the general public know that mental health is a scientific health problem and not a result of witchcraft.
“We do not have the figures yet, but after Covid-19, many employers across the country approached us, asking for advice on how to integrate mental well-being within the workplace culture. Some had lost staff; others had laid off staff, while others were working a few hours. The incomes and workloads had drastically changed, and employees were failing to cope,” he says.
Mbuga adds that toxicity in a workplace is relative, although it does not take much for a work environment to become toxic.
“Some employers pay their staff highly but do not allow them to take breaks. Their leave is restricted and if they become sick, they can be dismissed. Some companies do not offer health insurance to their workers. In some cases, superiors abuse their juniors for sexual favours or monetary kickbacks. If the juniors do not comply, they are harassed. I have seen job adverts in newspapers that require candidates to work under pressure. How can such an advert be allowed to run in the media?” he asks.
In situations where people are excluded from key decision-making or where decisions are made from outside the company, the lack of communication and bureaucracy can lead to anxiety and frustration, which will be reflected in absenteeism and poor productivity.
Prevalence
Last year, a study conducted by Makerere University School of Public Health and Butabika Hospital and released by the Ministry of Health found that one in three Ugandans is struggling with poor mental health.
Vivian Kudda, a clinical psychologist with Minders Wellness and Psychological Centre, says more men are committing suicide, while more women are attempting to do so, but failing. She also notes that more men are affected by substance abuse, while more women are affected by depression. Unfortunately, there are no systems in place to capture mental health support data, making interventions difficult.
Women are known to have access to accountability partners, such as friends, spouses, and siblings, who they can open up to when struggling with anxiety and depression. On the other hand, men tend to keep their struggles to themselves because they do not want to show vulnerability. Kudda also highlights that chronic stress is a growing concern among the working class.
She brings up the issue of retirement, mentioning that if individuals have been working under stressful conditions since a young age and have not planned for their retirement, the quality of their lives will be compromised. Kudda emphasises the need for conversations about exercising, making social connections, and eating a healthy and balanced diet from a young age to avoid stress-related ailments in old age.
Is HR responsible for employees’ mental well-being?
The blame for toxic work environments is often put on the ‘uncaring attitude of the human resource (HR) department’. Ronald Bbosa, the president of Human Resource Managers Association of Uganda, argues that HR is a strategic partner, change champion, and administrative expert of the business, not a counsellor.
“In HR, you are a referee, a counsellor, and a coach. These objectives may compete, complement, or conflict with each other.
However, the responsibility for the mental well-being of employees should lie with everybody who gets results from them and also with the business owner. If a head of department says everyone who suffers a mental breakdown should be sent to HR, at the end of the day, HR will not fulfill its core roles,” he says.
Bbosa adds that instead of focusing on the HR department, people should look to spouses as the best counsellors for people dealing with mental health issues. Mental health has physical, social, and psychosocial dimensions and Mbuga says integrating mental wellbeing into an organisation’s culture is necessary.
“Companies must put in place some infrastructure to foster a culture of mental wellbeing. For instance, if an employee develops a mental condition and is on medication, adjustments can be made so that they do not have to come in every day or they can come in but take several breaks in between work, or they can even work from home,” he says.
HR departments can also encourage managers, supervisors, and team leaders to have conversations about mental health with their juniors.
“It is important that every employer creates an environment where people are free to experiment because, for the last three years, mental health has been at the centre of our conversation as human resource professionals. Unfortunately, most companies think that when mental health issues are mentioned, that is an opportunity to go for team building exercises, instead of tackling the issues in the workplace that are driving people to depression and anxiety,” Bbosa says.
Bbosa adds that organisations should abandon outdated employee engagement surveys.
“The rise in mental health awareness among employees is happening at a time when we have talent on wheels. There is a very high turnover. An employer cannot wait to track the employees’ commitment and satisfaction levels at the end of every year. You need real-time approaches to be able to track your people’s happiness and satisfaction levels at the end of every day before they clock out, and be able to keep that data,” he says.
Studies have shown that annual employee surveys do not work because of the human tendency to give more weight to events that have occurred recently and assign less importance to those that occurred earlier.
Should medical insurance cover mental healthcare?
When Nsimbi had her fifth child, she suffered another mental breakdown. Her baby was four months old.
“My fourth baby cried a lot. She would cry from midnight to 3am every day and it was hard for me. I had no one to talk to. Sometimes, I could not go to work yet I had obligations to fulfill at my workplace. She preferred breast milk so, I would express the milk in a bottle but I would return from work when she had only taken a few sips. She was very clingy. One day, it became too much for me to handle,” she says.
This time, Nsimbi was hospitalised for eight days and after leaving the hospital, she was given three kinds of medication. For one of them, a tablet cost Shs3,000 and she had to take two a day. For an employee who does not have support, the cost of medication might be unbearable. Some therapy sessions around Kampala City range from Shs100,000 to Shs150,000 per hour.
“Yes, people cannot afford mental health services, but are the services even available? The majority of the services are concentrated in Kampala City, but what happens to employees in upcountry districts?” Kudda asks, adding, “There are few mental health professionals and in most cases, people seek their services when it is too late; after trying out so many different things. By this time, they have crossed over from borderline to severe. I think the question should be skewed more on how much do people know about mental health?”
Kudda advises that workplaces should be intentional about creating mental health awareness if they want to increase the productivity levels of their employees.
“When we go to workplaces to create awareness, senior management does not attend the sessions. These are influential people, the decision-makers, who will assent to the release of funds for mental health programmes. If you do not have their buy-in, then there is little you can do. Organisational leadership has to understand and appreciate that the integration of a mental health culture into the organisational culture is not the job of HR. It involves the entire workforce,” she says.
The question about why insurance companies rarely integrate mental healthcare into their packages, remains. It could be that psychotic drugs are expensive or that employers expect their employees to just walk into Butabika Hospital for medication.
“It is rare to find medication in public health facilities all the time. That is why employers need to negotiate mental healthcare in the medical insurance scheme. Insurance is about negotiation. Employers dictate the pace; for me to choose your insurance company, I need these packages, and if you do not have them, I will negotiate with the next insurance company,” Mbuga says.
Bbosa laments the gaps that are created when insurance companies do not record mental health data.
“People who provide medical insurance do not make an effort to ensure that the data that points in the direction of a mental breakdown is recorded or kept. Whoever is negotiating insurance packages should ensure that mental health awareness is included. Then, the reports should also be given, such as, who is frequenting the hospital, and what issues are they presenting,” he says.
There is a general assumption, though; that mental health problems can only be fixed by access to medication, yet a more holistic approach is needed, especially if the mental health triggers are social.
Mental health as a social problem
Mbuga believes that mental health issues are more of a social problem than a clinical one. He advises that rather than investing more money in institutional care, the country should bolster community mental health services provision.
“People fear hospitals, so community mental health services will attract more people. For instance, the capacity of families as first-line responders should be improved to enable them offer psychological first aid when the moment of distress comes. How can you provide capacity to the family so that they do not just bundle the victim down and tie them up and throw them on the back of a police truck?” he asks.
Mbuga adds that sometimes, mental conditions can be temporarily managed by de-escalation and supporting the victim to stay calm.
“De-escalation assures the victim that you are trying to address the problem and that you care. Also, the government needs to spend more on prevention. Look at the way we treat alcoholism. People get discharged from institutions and they are welcomed back with gourds of local brew. Within a short time, they are back in the institution, with the government spending more on them,” he says.
However, mental health treatment is still shrouded in stigma. Nsimbi says although her husband’s family was there for her, they have never directly discussed her mental episodes.
“I married into a Ganda family, and Baganda are known for keeping things hush-hush; sweeping them under the carpet. Yes, they showed up for me and cared for me in the hospital, but they did not talk about it. They were not comfortable talking about some things. It is like that phase of my life never happened. Although our relationship was strained for a while, my husband supported me, bringing articles on bipolar disorder for me to read. I understood he was making an effort to understand the condition.
When I was hospitalised, even though I could not hold my baby, he brought her and placed her near me. It made me happy,” she says.
Now a mental health activist, Nsimbi says women are not given a chance to rest. After she was discharged from the hospital, she had to return to her role of mothering and had to go back to work.
“Combatting stigma in the workplace is key. When you have gone through mental breakdowns, you feel ashamed, afraid, and you lose confidence. The psychotic medication made me gain weight, and I remember an insensitive workmate asking what had happened to me. But then, in 2013, I began talking about my mental health issues, and people’s attitudes started to change,” she says.
Employee assistance programmes
To create an enabling environment intentionally, organisations need to establish mental health policies, just like they have HR policies. A mental health policy can allocate spaces where individuals can take a break, specify whom to approach if someone is facing an issue, and set the number of days off allowed for self-rejuvenation. Employees need to have confidence in the mental health policy.
Companies need to foster environments where individuals can openly address their well-being, and management should be receptive. Failure to do so may result in high levels of absenteeism, employee turnover, and even “presenteeism,” where individuals show up for work but are not fully productive. Moreover, companies should equip their staff to provide psychological first aid to their colleagues. It is important to promote sharing experiences with peers, as keeping emotions bottled up can lead to mental breakdowns and potential long-term reliance on psychiatric medication,” advises Mbuga.
Some companies have implemented voluntary employee assistance programmes, which provide free assessments, short-term counselling, referrals, and follow-up services to employees dealing with personal and/or work-related challenges.
Kudda emphasises that employee assistance programmes are not as costly as some employers may believe. She suggests that companies seek guidance and support from the Uganda Counselling Association and learn from other organisations about how they have established structures for addressing employee mental health concerns. When senior management demonstrates concern for employees’ well-being, companies tend to witness increased productivity.
As a precautionary measure, Bbosa advises employees to focus on things within their control and let go of matters beyond their influence.
“People worry about the 2031 general election or the Premier League. These are things we cannot control. Also, every organisation should have a succession plan. The environment in which we spend many hours every day must offer a degree of predictability to provide people with a sense of psychological safety,” he says.
Although there are few statistics on how much Uganda loses annually due to poor mental health, data indicates that individuals with mental illnesses are more likely to drop out of school or work, significantly impacting the country’s human resources.
