Cover image courtesy of Torre Costanza, The London School of Economics and Political Science: Department for International Development.
Written by Elyse Graham, The University of Oklahoma
Throughout the last half-century, western organizations such as Network for Africa (N4A) have emerged in an attempt to provide mental health services and community support to individuals in post-conflict regions. This essay critically analyzes the paradoxical nature of Network for Africa’s work in the post-conflict region of Northern Uganda, located in Eastern Africa. Although there are widely positive outcomes from Network for Africa’s mental health interventions, criticisms of mental health humanitarianism revolve around the question of whether or not the resources and training provided are culturally appropriate. Because the majority of mental health research has been conducted based on the study of individuals in westernized cultures, it is essential that humanitarian organizations modify their psychological approaches in order to better fit the needs of the community on the receiving end. This can be done through extended contact with the local culture, direct communication with health experts in these regions, and by shifting toward using the theory of ‘practice-based evidence’ rather than ‘evidence-based practice’. Despite the ethical challenges to mental health research and the obstacles created by cultural diversity, it becomes clear throughout this critical assessment of primary and secondary sources that Network for Africa’s actions are successful at adapting to the needs of the local Ugandan cultures.
Found in Palabek, a town located in Northern Uganda, this sign was placed by the Republic of Uganda Ministry of Health in order to encourage refugees and locals to utilize mental health resources offered by local organizations .
Although not as globally recognized as other humanitarian organizations such as the Red Cross or Médecins Sans Frontières International, Network for Africa (N4A) has emerged as a key player in the global humanitarian response to recent crises in Northern Uganda. Founded in 2007 by former British political journalist Rebecca Tinsley, Network for Africa works to “help survivors of genocide [and other humanitarian crises] rebuild their lives” through providing psychosocial support and mental health resources to local populations in West Africa . According to the organization’s mission statement, Network for Africa strives to provide post-conflict communities with the skills to not only identify individuals struggling with mental health issues, but also to provide them with sustainable counselling alternatives, reliable mental health resources, and overall the ability “to rebuild their lives through education, health and livelihoods” . The organization claims to prioritize working “after the fighting stops and the humanitarian aid moves on”, taking into consideration the “long-term psychological consequences that often block” the recovery of post-conflict communities . Although there are numerous reports of positive outcomes resulting from Network for Africa’s mental health interventions in Uganda, it is necessary to assess whether or not the resources and training provided are culturally appropriate. This is a western organization staffed by westerners and founded on western ideals and research. Especially in the study of mental health and the psychosocial wellbeing of societies, the majority of research being conducted focuses on the assessment of individuals in westernized cultures. Therefore, it is essential that humanitarian organizations modify their psychological interventions and resources when working in non-western communities to better fit the needs and ideals of the local population on the receiving end.
The History of Mental Health and Crisis in Northern Uganda
According to the World Health Organization (WHO), “[i]n low- and medium-income countries like Uganda where disease, ignorance, and poverty are common, a demand for a steadfast mental healthcare can often seem a luxury” . In addition to this, though, there are a number of obstacles that mental health advocates face in this region. From the late 1980s up until 2006, a Ugandan militant group known as the Lord’s Resistance Army (LRA) terrorized West Africa by waging “a war of attrition against the government and peoples of Uganda and nearby countries” . The rebel group, led by Ugandan Joseph Kony, had an especially harsh impact in the Agago District of Uganda, located in “a remote and neglected corner in the northeast of the country” . The Lord’s Resistance Army killed and terrorized numerous civilians, abducted and tortured children, and displaced more than 1.7 million people during this war. As a result, local communities in the Agago District of Uganda were left with scarce resources, no stable government, and over time, these local cultures deteriorated as the wellbeing of their members suffered.
However, this conflict caused by Kony and the Lord’s Resistance Army is not the only problem that mental health advocacy organizations such as Network for Africa face in Uganda. Even prior to the conflict and mistreatments created by the conflict between the militant Lords’ Resistance Army and the Ugandan People’s Defence Force, many cultures within Uganda have traditionally associated mental illness with being a burden or expressing weakness . Because of this negative connotation that these local cultures sometimes associate with mental diseases, very few individuals address and seek help for their struggles as they fear judgment from their peers. Other issues arise in the low financial support that the government provides to public health — especially mental health — systems. For example, Molodynski et al. found that while “Uganda spends 9.8% of its gross domestic product on healthcare… [however] just 1% of this goes into mental healthcare” ; . Similarly, Mugisha et al. discuss the trends in mental health service participation in Uganda and possible implications, claiming that “[m]ental, neurological and substance use disorders are a public health burden in Uganda” because of the “low mental service user participation” at both the local and national levels . With the fear and disorder caused by the conflict with the Lord’s Resistance Army and now the COVID-19 pandemic, local populations in Uganda are experiencing some of the highest rates of mental illness in the world. On one hand, President Museveni’s enacting of the Ugandan Mental Health Act in 2018 serves as evidence of improvement in community support of and access to effective mental health services in the decade following Network for Africa’s founding as the country is seen making legislative action to further develop the nation’s mental health system. This governmental bill sought to create a national Mental Health Advisory Board, “provide for the protection of the rights of persons with mental illness”, and to regulate and advance the treatment of individuals with mental health disorders in the Republic of Uganda . While we can applaud Network for Africa for these improvements in overall Ugandan access to mental health resources, we also have to look at the approaches the organization uses to assess whether or not it prioritizes the community on the receiving end in a culturally appropriate, unbiased, and effective way. This can be done using the World Health Organization’s Assessment Instrument for Mental Health Systems, which is a tool established “primarily for assessing mental health systems in low and middle-income countries” . In 2006, the World Health Organization Uganda Office, Regional Office for Africa, and Department of Mental Health and Substance Abuse used the AIMS criteria to assess the state of mental health systems in Uganda, concluding that there was a relatively high percentage of individuals struggling with illnesses such as anxiety, depression, and PTSD yet a low percentage of those individuals seeking counseling or other mental health resources . Throughout both of these reports, the Ugandan employees of the World Health Organization and the Republic of Uganda Ministry of Health focus on assessing whether the needs of different cultures within Uganda are being met effectively. Using these same standards of mental health assessment defined by the World Health Organization’s AIMS tool and Report on Mental Health Systems in Uganda, one can assess the general effectiveness of Network for Africa’s interventions by evaluating whether or not the organization works with and for the Ugandan community being helped.
Network for Africa’s Interventions in Northern Uganda
Developed as a product of the United States Agency of International Development’s Strengthening Health Outcomes through the Private Sector (SHOPS) project, Network for Africa began their work in Africa by slowly developing partnerships with local non-governmental organizations located primarily in countries directly affected by the threats of genocide and intense conflict: Rwanda, Sierra Leone, and Uganda . After partnering with these organizations, Network for Africa works with their local counterparts to identify the most important issues facing each community. In Uganda, post-traumatic stress disorder (PTSD) and generalized anxiety disorders were identified by individuals in the Agago District to be two of the biggest threats to the community’s psychosocial wellbeing. After these key issues were identified by locals, Network for Africa studied the mental health patterns present within the population, proposed effective mental health interventions to their local partner organizations, and asked for “advice on how to adapt training [of western volunteers] to the specific local needs and culture” . According to the organization’s website, before Network for Africa directly addresses the public, they work with local individuals who are able to educate their western counterparts on the values of the culture on the receiving end, the cultural differences that volunteers will likely observe, and overall provide them with a reliable, first-hand perspective of the needs of each society. This ensures that the organization will not overlook simply cultural differences and allows for the perspective of local individuals to be considered before the intervention takes place.
Once the planning portion of the project is completed, Network for Africa sends a small crew of expatriates to “train local community counsellors, medical professionals, officials and leaders to respond to mental health issues” such as PTSD, anxiety, and depression . Network for Africa claims to work in a practical and cost-effective way by supporting existing healthcare facilities and empowering local non-governmental organizations employed with individuals who know the primary demands and issues within each community rather than bringing in international volunteers with little-to-no knowledge of local needs and expectations. The organization helps their “local partner NGO to build a coherent team, trained and capable of delivering counselling, being role models, keeping records of each client and each group, and supporting each other so they don’t burn out” and so that the community will continue to thrive after Network for Africa has ended their humanitarian project .
There are many sources that support the claims that Network for Africa’s mental health interventions have been both successful at adapting to the needs of the local Ugandan cultures and effective in increasing the public’s access to reliable psychosocial support resources. For example, in a 2021 report, the organization claimed that in the prior calendar year there had been over 700 new patients treated in Agago District mental health clinics, 25 new formal self-help and counselling groups had been formed, and over 20,000 local individuals were trained to provide trauma counseling, HIV patient counseling, and treat other trauma-related mental health issues . Another blog post from the organization’s official website describes the growing demand for self-help groups in post-conflict Uganda and its connection to the “self-help movement” . The author of this piece provides strong evidence for Network for Africa’s success in teaching communities to become self-sufficient, which is one thing the organization does better than most. At the same time, though, the author discusses one consequence that may arise from this trend: because of the growing popularity of self-help groups and counseling, the “demand for… counselors…is outstripping [the] supply”, creating a greater risk for harmful or ineffective interventions by Network for Africa . Essentially, since the organization is limited in the number of volunteers they are sending to the Agago District, they are also limited in how many counseling groups they can sustain and therefore how many local Ugandans they can reach. As the same number of volunteers interact with more and more individuals, they are becoming less able to create a personal connection with those they are helping. The self-help movement’s effect on the growing demand for trained counselors only increases this strain put on Network for Africa’s volunteers, therefore increasing the possibility that the mental health care being provided may not be as thorough or effective as it should be.
In addition to this, one can also find multiple testimonies of those helped by Network for Africa. An example of this is seen in the quote below, which was taken from Network for Africa’s Twitter account and posted in March of 2021. The included quote from a 44-year old Ugandan woman living in the Agago District reads:
“In the past, I used to have mental problems; all the people in my area knew it. They kept away from me. One day at church I was told that there is an organisation that provides mental health services. I went to the hospital, got registered and was given medicine. Before I started using the medicine, I was guided on how to use it. I have improvement in my life because the mental illness used to disturb me and disrupt my work. I feel that there is great improvement, I have resumed my work at school and now I can stay among my fellow teachers. The staff visited me at home to remind me to take my drugs regularly. This has created a big impact in my life. Now that I have been receiving treatment, I will continue adhering to medication” .
This testimony supports the claim that Network for Africa’s efforts have been positively received by most of Uganda’s population, while also providing an example of the stigma that has traditionally surrounded mental health services in Uganda. Even though this organization is working to minimize the stigma surrounding mental health in Eastern Africa, as authors Kagaari and Mugisha et al. suggest, the reality is that it is so deeply ingrained in Ugandan culture that it may never completely fade ; .
Primary Concerns for Providing Culturally Appropriate Mental Health Support
As can be seen in numerous humanitarian projects between multiple organizations, “psychological tools and approaches are sometimes used in ways that cause unintended harm” due to cultural differences and a lack of cultural awareness . Gopalkrishnan makes a similar statement, arguing that “differences in cultures have a range of implications for mental health practice, ranging from the ways that people view health and illness, to treatment seeking patterns, the nature of the therapeutic relationship and issues of racism and discrimination” . Because of these implications created by cultural differences, western helpers oftentimes provide westernized and somewhat ineffective mental health services. In order to ensure this does not happen, it is important that organizations actively work with local populations to provide their recipients with contextually appropriate mental health resources.
Throughout academic literature, authors and researchers have proposed various ways of increasing cultural learning and flexibility while decreasing cultural biases. Wessells, for example, argues that we can provide more “contextually appropriate psychosocial support” in post-conflict regions with “the use of critical self-reflection, greater specificity in ethical guidance, a stronger evidence base for intervention, and improved methods of preparing international humanitarian psychologists” . Essentially, Wessells is asserting that it is necessary to address cultural and contextual differences and insensitivities before volunteers are exposed to entirely new cultures. This article is important in arguing that Network for Africa has successfully adapted to provide contextually appropriate support. However, this does not mean that the actions of the organization are perfect or ideal. In order to continually improve the effectiveness of their interventions, Network for Africa must be continually learning, questioning, and adapting to local differences when providing international humanitarian aid.
In a different essay, author Hanna Kienzler argues that in order to make mental health system reform effective, humanitarian organizations must shift toward using the theory of practice-based evidence rather than evidence-based practice. Practice-based evidence is a theory founded on learning-by-doing, and therefore “would allow us to explore more fully the complexity of building health systems and practices of delivering mental health care in settings affected by conflict, instability, and resource-scarcity” . Although Network for Africa has failed to embrace some aspects of practice-based evidence, the organization is taking slow steps to increase the number of western and Ugandan volunteers directly involved in local Ugandan communities. Therefore, this source can be used to support the argument that Network for Africa is gradually becoming more integrated with local cultures in Uganda, increasing the effectiveness of their mental health initiatives as they become more knowledgeable on local differences and values.
Lastly, it is important to also consider the ethical challenges that mental health researchers and volunteers face during international projects. According to Chiumento et al., there are six main challenges during international humanitarian work: who conducts the research, who funds the research, ethical review, informed consent, community mistrust, and potential risks to researchers . Each of these challenges can affect whether or not the local population will be accepting of western intervention, therefore it is important that Network for Africa and other organizations like it are addressing these challenges in order to produce valid, reliable, and ethical mental health research. As can be seen in the previously quoted testimony from Ugandan recipients being helped by Network for Africa, the Ugandans generally receive the organization’s interventions well as they actively work with Ugandan officials to gain the trust of local populations and conduct reliable research. Network for Africa is not only making sure to include the local perspective in the decision-making process, but they are also promoting the development of long-term, self-sufficient public and mental health systems that will survive long after this short-term mission ends.
In the end, to get the most accurate gauge of how effective and culturally appropriate Network for Africa’s mental health interventions were in the Agago District of Uganda, it is important to assess four aspects of their actions:
- The organization’s motives,
- The ability of the organization to adapt its actions to the needs of the local population,
- To what extent the interventions and resources were accepted by the receiving population, and
- Whether or not positive change was observed following the intervention.
Founder Rebecca Tinsley makes her intentions in founding Network for Africa fairly clear, stating that the organization was founded out of an attempt “to help survivors of genocide rebuild their lives” . The organization’s mission and vision statements also closely align with Tinsley’s ideals, calling for all individuals to “challenge the stigma attached to trauma, depression and mental illness” in Uganda in a culturally appropriate way . Therefore, looking solely at the motivations behind Network for Africa’s actions, one can assume that they are actively working to provide appropriate care to Ugandans in the Agago District. However, as Ivan Illich discussed in his 1968 address to the Conference on InterAmerican Student Projects (CIASP), good intentions are not enough to justify the effects of any humanitarian actions, especially when they result in harmful, unintended consequences.
Next, we can look at the ability of the organization to adapt its actions to the needs of the local population. This can be done in many ways, as discussed throughout this analysis. A few of the suggested methods that non-governmental humanitarian organizations can use in order to adapt to the needs of the local populations being helped include shifting towards a theory of practice-based evidence , actively addressing the ethical challenges to mental health research that oftentimes arise , and providing “contextually appropriate psychosocial support” in post-conflict regions with “the use of critical self-reflection, greater specificity in ethical guidance, a stronger evidence base for intervention, and improved methods of preparing international humanitarian psychologists” . Although Network for Africa has not fully embraced any one of these methods, the organization has gradually blended all of these suggestions together in order to provide more culturally appropriate care to individuals in Northern Uganda. Clearly, looking only at the ability of the organization to adapt to the needs of local cultures, one could again argue that Network for Africa is actively making efforts to become more culturally flexible. They are doing this by providing cultural bias training to international volunteers, by educating expatriates thoroughly before sending them to work in another culture, and by partnering with Ugandan organizations that are able to express the local viewpoint during the decision-making process.
Third, we can assess to what extent the interventions and resources introduced by Network for Africa were accepted by the Ugandan population. On one hand, by looking at the 44-year old woman’s testimony quoted on page seven and the spontaneous emergence of informal self-help groups in the Agago District, one could argue that the Ugandan population is generally accepting of Network for Africa’s resources. However, studies conducted by Mugisha et al. suggest that there is a generally low rate of “mental service user participation” at both the local and national levels in Uganda . Despite the widely positive outcomes of Network for Africa’s interventions discussed so far, this fact suggests a possible shortcoming of the organization’s interventions in Uganda. Although there have been many positive effects, a large percent of the population is still not using the mental health resources they are being offered. A future initiative or goal for Network for Africa should be increasing mental health service participation, which will happen as the organization slowly addresses the stigma surrounding mental health and raises awareness on the prevalence of mental health issues.
Lastly, it is also important that we determine whether or not positive change was observed following the Network for Africa’s intervention in Uganda. We can assess this looking at the statistical outcomes from three different humanitarian projects in Uganda: The Livelihood Support for People with Mental Health Issues (The National Lottery Community Fund) and The Community Health Matters (Comic Relief) Project in the Agago District, and The Community Counselling Outreach Project in Patongo. The data from all three of these projects indicated an increase in awareness about mental health issues, the stigma around them, and an increasing number of individuals seeking treatment as a result of the organization’s intervention in the community, supporting the claim that Network for Africa is having visible and quantifiable positive effects in Uganda. In general, each of these projects by Network for Africa led to an increase in access to mental health resources for the general population, a decrease in the cultural stigma surrounding mental health issues in Uganda, and an increasing number of individuals seeking help, whether it be through counseling or self-help groups with their peers. This helps to not only “reduce loneliness and stigma, increase self-esteem and social functioning, improve coping skills and help acceptance of medical conditions”, but it also allows for the rebuilding of culture and social wellbeing for Ugandans so that they will hopefully become self-sufficient in the near future .
Assessing all four of these aspects of Network for Africa’s actions in Uganda, it becomes clear that despite the ethical challenges to mental health research and the obstacles created by cultural diversity, Network for Africa’s actions are generally successful at adapting to the needs of the local Ugandan cultures. Especially following the turmoil and chaos created by the Lord’s Resistance Army and pre-existing cultural stereotypes surrounding mental health illnesses, there have been major improvements in Ugandan access to adequate mental health resources. Even though Network for Africa is a western organization founded on western ideals, it is clear the organization is actively making efforts to work with local Ugandan populations so that they are aware of cultural differences and able to provide contextually appropriate psychosocial care.
This post may have been edited by admin for clarity and length.
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 “Report on Mental Disorders.” World Health Organization (WHO), 28 Nov. 2019, who.int/news-room/fact-sheets/detail/mental-disorders
 Bunting, Ikwebe. “Lord’s Resistance Army”. Encyclopedia Britannica, 24 Aug. 2017, https://www.britannica.com/topic/Lords-Resistance-Army.
 “Projects: Uganda.” Network4Africa.Org, Network for Africa, 2020, network4africa.org/projects/uganda/.
 Kagaari, James. “Mental Health in Uganda.” Apa.org, American Psychological Association, 26 Jan. 2021, apa.org/international/global-insights/uganda-mental-health.
 Molodynski, A., Cusack, C., and Nixon, J. (2017). Mental healthcare in Uganda: Desparate challenges but real opportunities. BJPsych International, 14 (4).
 Mugisha, James, et al. “The Experience of Mental Health Service Users in Health System Strengthening: Lessons from Uganda.” International Journal of Mental Health Systems, vol. 13, no. 1, 6 Sept. 2019, doi:10.1186/s13033-019-0316-5.
 Museveni, Yoweri. The Mental Health Act, 2018. Ugandan Parliament Library, 2019.
 “WHO-AIMS: World Health Organization Assessment Instrument for Mental Health Systems.” World Health Organization, 2005.
 “WHO-AIMS Report on Mental Health Systems in Uganda.” World Health Organization and The Republic of Uganda Ministry of Health, 2006.
 BEAM Exchange. “Network For Africa (N4A)”. BEAM Exchange, https://beamexchange.org/resources/210/.
 “About Us: Network for Africa’s Unique Approach.” Network4Africa.Org, Network for Africa, 2021, network4africa.org/about-us/.
 “Mental Health: Progress So Far.” Network4Africa.Org, Network for Africa, Jan. 2021, network4africa.org/mental-health/progress-so-far/.
 “Getting By With A Little Help From My Friends: The Growing Demand For Self Help Groups in Uganda.” Network4Africa.Org, Network for Africa, 3 Feb. 2021, network4africa.org/getting-by-with-a-little-help/.
 “Uganda – Testimonies from Our Livelihood Support For People with Mental Health Issues, Agago District.” Twitter.com/Network4Africa, Twitter Web Application, 25 Mar. 2021, twitter.com/Network4Africa/status/1375143611076083720.
 Wessells, Michael G. “Do No Harm: Toward Contextually Appropriate Psychosocial Support in International Emergencies.” American Psychologist, vol. 64, no. 8, Nov. 2009, pp. 842–854., doi:10.1037/0003-066x.64.8.842.
 Gopalkrishnan, Narayan. “Cultural Diversity and Mental Health: Considerations for Policy and Practice.” Frontiers in Public Health, vol. 6, 19 June 2018, doi:10.3389/fpubh.2018.00179.
 Kienzler, Hanna. “Mental Health System Reform in Contexts of Humanitarian Emergencies: Toward a Theory of ‘Practice-Based Evidence.’” Culture, Medicine, and Psychiatry, vol. 43, no. 4, 15 Nov. 2019, pp. 636–662., doi:10.1007/s11013-019-09641-w.
 Chiumento, Anna, et al. “Managing Ethical Challenges to Mental Health Research in Post-Conflict Settings.” Developing World Bioethics, vol. 16, no. 1, 8 Jan. 2015, pp. 15–28., doi:10.1111/dewb.12076.