The mental health treatment gap in South Sudan

Author(s): Joseph Lou K. Mogga

National Professional Officer (NPO), Noncommunicable Diseases and Mental Health, World Health Organization, South Sudan


Correspondence: Joseph Lou K. Mogga [email protected]

What is a mental health treatment gap?

A mental health treatment gap is the percentage of individuals who require treatment in a country or in a defined community but do not receive it. The reasons for this include: non-availability or poor access to services and stigma [1].

How large is the gap in South Sudan?

South Sudan has one of the largest mental health gaps in the world. The World Health Organization (WHO) estimates that during humanitarian emergencies, rates of mental health disorders can increase up to 4% for severe conditions and up to 20% for mild to moderate disorders requiring care and support [2]. South Sudan Health Cluster projections estimated that 5.1 million people are affected by the ongoing humanitarian emergency in the country [3]. This amounts to an estimated 204,000 people with severe and 1,020,000 people with mild to moderate mental health conditions in South Sudan. This could be imputed to conditions resulting from the humanitarian situation. In contrast, current humanitarian efforts by various partners are reaching less than 10,000 persons per year (1%). Therefore, the estimated mental health treatment gap among the population of humanitarian concern is a staggering 99%.


Table 1. Impact of disasters on the prevalence of mental health conditions


Before disaster:

12-month prevalence

After disaster:

12-month  prevalence

Estimate total cases with mental health condition for the population of humanitarian concern (5.1million. source:- Health Cluster – June, 2018[3])

Severe disorder

(e.g., psychosis, severe depression, severely disabling form of anxiety disorder)








Mild or moderate mental disorder (e.g., mild and moderate forms of depression and anxiety disorders)





15% - 20%




"Normal" stress reactions (no disorder)

No estimate


Large percentage

No estimate

Source: Van Ommeren et al. BMJ; 330:1160-1; 2005; [2]

Why do we have a mental health treatment gap in South Sudan?

Mental health conditions are prevalent and untreated in the population [4]. A study in Juba found that 36% of the sampled population met the criteria for Post Traumatic Stress Disorder (PTSD) [5]. In addition to this, rates of mental health disorders increase during emergencies. The low level of resources allocated to mental health services limits their ability to reach affected people. There are still unprecedented levels of stigma directed to persons with mental health disorders in the country, this discourages people from accessing help [6]. The poor performance of mental health services contributes further to the treatment gap.  In many situations the services are unavailable, inaccessible and inadequately supervised.

What are the implications of the mental health treatment gap?

The huge treatment gap means that persons with mental health disorders that are not receiving the care and treatment they require are likely to function poorly in the community. This drives them and their families deeper into poverty. In addition, due to limited participation in community activities and limited employment opportunities, many are likely to have a poor quality of life. Rates of teenage pregnancy and domestic violence are likely to increase. Moreover, persons with untreated mental health conditions have increased mortality rates.  Mental health legislation is intended to ensure that people with mental health disorders receive the care they need and to which they are entitled.  A consequence of lack of such legislation in South Sudan is that, many people with mental health disorder are likely to be incarcerated even if they have not committed a crime.

What can be done to reduce the mental health treatment gap?

Service re-organization and expanded coverage: This entails discouragement of plans to establish long-stay psychiatric institutions but instead to invest in outpatient and inpatient mental health services in general hospitals. Mental health services should be integrated into other health programmes such as the Boma Health Initiative, primary and secondary health care as well as traditional health practitioners (traditional healers) services. The establishment of community services such as home and emergency outreach, rehabilitation and supported housing facilities will contribute to closing the treatment gap. 

Implement Integrated and Responsive Care: this involves linking people to available resources elsewhere and cultivating recovery oriented care. It is also important to empower people with mental health disorders and their families. Resources should be allocated to ensure the availability of medicines and provision of services for people facing adverse life events in line with the WHO Quality Rights Standards.

Address resource planning: including capacity building for mental health in non-specialized health settings (primary health care and general hospitals) using the WHO Mental Health Gap Action Programme – Humanitarian Intervention Guide (mhGAP – HIG). There is a need for task definitions, referral structures and supervision for trained health workers. It is also important to improve the capacity for social care workers (clinical, human rights and public health); and improve the working conditions for the mental health workforce.

Leadership: Improve government stewardship and prioritization of mental health across line ministries.

Acknowledgement: Dr Itzhak Levav and Dr Alberto Minoletti, Faculty members, International Diploma in Mental Health, Human Rights, India Law Society, Pune, India, on whose lectures in 2017 and 2018 this article is based. Both have approved it for publishing in the South Sudan Medical Journal.


  1. Pathare S, Brazinova A, Levav I. Care gap: A comprehensive measure to quantify unmet needs in mental health; Bull World Health Organ. 2004 Nov; 82(11):858-66. Epub 2004 Dec 14.
  2. Van Ommeren et al. BMJ 2005; 330:1160-1;
  3. South Sudan Health Cluster Bulletin, Number 8; August 2018. Search
  4. Kohn R1, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care; Bull World Health Organ. 2004 Nov; 82(11):858-66. Epub 2004 Dec 14.
  5. Sieta Adhieu Majok. Mental Health in South Sudan: A ticking Time Bomb. South Sudan Medical Journal 2018 August; 11(3):55.
  6. Ayazi T, Lien L, Eide A, Shadar EJ, Hauff E.Community attitudes and social distance towards the mentally ill in South Sudan: a survey from a post-conflict setting with no mental health services. Social Psychiatry and Psychiatric Epidemiology 2014 May; 49(5):771–780.