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Building bridges for mental health care in South Asian region
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Thirunavukarasu M1 & Shyam Sundar A2 1 Professor and Head, Department of Psychiatry, SRM medical College Hospital and research Centre, India 2 Assistant Professor, Department of Psychiatry, SRM medical College Hospital and research Centre, India |
Abstract: Recent estimates have demonstrated that mental health problems cause considerable morbidity and burden on individuals and society. Despite this, a large part of the suffering population worldwide does not receive adequate treatment, especially in the less developed nations. The nations belonging to the SAARC conglomeration share the twin problems of increased burden of mental illness and inadequate resources. In this article, we review the current resources available in the region and suggest that the way forward is to actively collaborate in developing and disseminating information; policy and service development; advocacy and research. Key words: Mental health, South Asia, SAARC, mental health resources, regional cooperation |
The Global burden of diseases (GBD) project, undertaken by the World Health Organization (WHO), estimated that neuro-psychiatric conditions accounted for 13% of the global burden of diseases in 2002, as measured by Disability Adjusted Life Years (DALY). Further, more than half of the 10 leading risk factors that cause one third of the premature deaths worldwide have behavioural determinants, such as unsafe sex, tobacco or alcohol consumption, etc. Worldwide, community-based epidemiological studies have estimated that lifetime prevalence rates of mental disorders in adults are 12.2% - 48.6% and 12-month prevalence rates are 8.4% - 29.1% (World Health Organization, 2008). These are some of the evidence that has underscored the importance of mental health in the global health scenario.
The South Asian Association for Regional Co-operation (SAARC) comprising of Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka and Afghanistan contains 23% of the world’s population. One fifth of psychiatrically ill patients in the world are said to reside in the South Asian region, estimated to be 150-200 million (Trivedi et al., 2007). The GBD project has shown that neuropsychiatric conditions cause significant burden among South Asian nations. The burden of neuropsychiatric conditions among South Asian nations in shown in table 1.
Table 1 - Global burden of neuropsychiatric conditions among South Asian nations |
Country |
DALYs (per 100000) caused by neuropsychiatric conditions |
% of total GBD |
Afghanistan |
4111 |
6.7% |
Bangladesh |
3077 |
11.2% |
Bhutan |
3110 |
12.1% |
India |
3228 |
11.6% |
Maldives |
4402 |
18.7% |
Nepal |
3395 |
11% |
Pakistan |
3188 |
11.9% |
Sri Lanka |
2865 |
11.5% |
Treatment gap
Despite the huge burden, most of the patients suffering from psychiatric illness do not receive treatment. A large multi-country survey supported by WHO showed that 35–50% of serious cases in developed countries and 76–85% in less-developed countries had received no treatment in the previous 12 months (World Health Organization, 2004). The absolute difference between the true prevalence of a disorder and the treated proportion of individuals affected by the disorder is termed as ‘treatment gap”. Treatment gap is found to be huge across all psychiatric disorders. A review of the world literature found treatment gaps to be 32.2% for schizophrenia, 56.3% for depression; 56% for dysthymia; 50.2% for bipolar disorder; 55.9% for panic disorder; 57.5% for GAD; 57.3% for OCD and as much as 78.1% for alcohol use disorders (Kohn et al., 2004). The treatment gap is caused by factors like stigma, lack of knowledge about psychiatric disorders and effectiveness of treatment, financial considerations, issues of accessibility, as well as limited availability or lack of availability of services (Kohn et al., 2004). The treatment gap is expected to be higher in low income countries due to scarcity of services. All the SAARC countries belong to the low income group and share the problem of inadequate resources to treat mental health problems.
Mental health resources in
South Asian nations
The Mental Health Atlas of the WHO provides information about the mental health resources in different countries. The resources include policies, programmes, financing, services, professionals, treatment and medicines, information systems and related organizations. These resources are necessary to provide services and care for people suffering from psychiatric illness. The last edition was released in 2005. The mental health resources of the SAARC nations are summarized in table 2 to 5.
Table 2 - Mental health resources in SAARC nations – Policy & legislation |
Country |
Mental health policy |
Substance abuse policy |
National mental health programme |
Mental health legislation |
Afghanistan |
√ |
√ |
√ |
√ |
Bangladesh |
X |
√ |
√ |
√ |
Bhutan |
√ |
√ |
√ |
X |
India |
X |
X |
√ |
√ |
Maldives |
X |
√ |
X |
X |
Nepal |
√ |
√ |
X |
X |
Pakistan |
√ |
√ |
√ |
√ |
Sri Lanka |
√ |
X |
√ |
√ |
Table 3 - Mental health resources in SAARC nations - Financing
Country |
Budget allocation for mental health |
% of total health budget spent on mental health |
Primary source of financing |
Disability benefits |
Afghanistan |
√ |
Details NA |
Out of pocket |
√ |
Bangladesh |
√ |
0.5% |
Tax based |
√ |
Bhutan |
√ |
0.17% |
Tax based |
√ |
India |
√ |
2.05% |
Tax based |
√ |
Maldives |
X |
Details NA |
Out of pocket |
√ |
Nepal |
√ |
0.08% |
Out of pocket |
√ |
Pakistan |
√ |
0.4% |
Out of pocket |
√ |
Sri Lanka |
√ |
1.6% |
Tax based |
X |
Table 4 - Mental health resources in SAARC nations – Integration with primary care |
Country |
Mental health as a part of primary care |
Training at primary care |
Community care facilities |
Afghanistan |
No |
No |
Yes |
Bangladesh |
Yes |
Yes |
Yes |
Bhutan |
Yes |
Yes |
Yes |
India |
Yes |
Yes |
Yes |
Maldives |
No |
Yes |
No |
Nepal |
No |
No |
No |
Pakistan |
Yes |
Yes |
Yes |
Sri Lanka |
Yes |
Yes |
Yes |
Table 5 - Mental health resources in SAARC nations – Human resources
Country |
Psychiatric beds per 10000 |
Psychiatrists per 10000 |
Psychologists per 10000 |
Psychiatric nurses per 10000 |
Social workers per 10000 |
Afghanistan |
0.055 |
0.036 |
0.09 |
0.07 |
0 |
Bangladesh |
0.065 |
0.05 |
0.002 |
0.06 |
0.001 |
Bhutan |
0 |
0.3 |
0 |
0.16 |
0 |
India |
0.25 |
0.2 |
0.03 |
0.05 |
0.03 |
Maldives |
- |
0.36 |
1.2 |
0 |
0 |
Nepal |
0.08 |
0.12 |
0.08 |
0.08 |
0.04 |
Pakistan |
0.24 |
0.2 |
0.2 |
0.08 |
0.4 |
Sri Lanka |
1.8 |
0.2 |
0.02 |
1.8 |
0.07 |
There are wide discrepancies with regard to mental health policies and legislation among SAARC nations. Three of the 8 SAARC nations do not have a mental health policy. Three SAARC nations do not have mental health legislation. In some countries which have such legislation, the laws are archaic and needs revision. Some of the countries are in the process of revising their mental health policy and legislation.
Although most SAARC nations (excepting Maldives) have a separate allocation in budget for mental health, the percentage spent on mental health is less than 1% in most countries. Compared to the burden of around 11% caused by neuropsychiatric illness in most SAARC nations, this allocation seems meager. The allocation of resources may be primarily based on mortality statistics. There is a need to shift to morbidity statistics for allocation of resources. The primary source of financing mental health care is either out of pocket or tax based, with poor insurance coverage. Considering these factors, there is a need to increase the budget allocation for mental health care.
Mental health is not integrated with primary care in 3 SAARC nations. The training at primary care is also inadequate. Other community care facilities are also poorly developed. The human resources are also grossly inadequate in all SAARC nations. For example, it can be seen from table 5 that the number of psychiatrists varies from 0.036 to 0.36 per 10000 population. This can be compared with the ideal of 1 per 10000 population.
Scaling up of resources
Hence a lot is to be desired in improving all type of mental health resources. Financial constraints are often cited as a reason for the poor mental health care in low income countries. The WHO CHOICE (CHOosing Interventions that are Cost Effective) programme has demonstrated that interventions for common mental disorders are very cost-effective i.e. each DALY averted costs less than one year of average per capita income and community-based interventions for severe mental disorders meet the criterion for being cost-effective i.e. each DALY averted costs less than three times the average annual income (Chisholm, 2005). Evidence exists that scaling up of metal health resources can be done with relatively lesser cost. The cost per capita of providing mental health care for mood disorders and schizophrenia in low-income countries range from $1.85 to $2.60 per year (Chisholm et al., 2007). Hence it has been amply demonstrated that mental health resources can be scaled up despite financial constraints.
Closing the treatment gap
WHO has recommended the following steps to close the treatment gap (World Health Organization, 2008)
1. Provide treatment in primary care
2. Make psychotropic medicines available
3. Give care in the community
4. Educate the public
5. Involve communities, families and consumers
6. Establish national policies, programmes, and legislation
7. Develop human resources
8. Link with other sectors
9. Monitor community mental health
10. Support more research
It has suggested four strategies to achieve this goal
1. Information
2. Policy and service development
3. Advocacy
4. Research
Despite vast cultural, religious, geographical and political diversities, the factors influencing mental health remain the same in the South Asian region (Trivedi et al., 2007). Hence the SAARC nations can cooperate among themselves in helping each other to close the treatment gap using these strategies. Some suggestions for SAARC nations for cooperation in these areas are briefly discussed.
Information
Information regarding epidemiology, burden, resources and treatment is needed to plan services and policy. The current level of information is patchy at best. Further, there is no mechanism for continuous monitoring and updating data. There is a need to promote establishment and maintenance of mental health and substance dependence monitoring and information systems in SAARC nations. There is the possibility of cooperation in developing such monitoring systems. For example, India has system for drug abuse monitoring – the expertise and technologies can be shared with countries which do not. A regional internet based database can be established for effective sharing of information. Currently, the treatment guidelines developed in Western nations are used in most countries, which may not be applicable to the local conditions. Hence the South Asian nations can form locally applicable guidelines for the treatment of psychiatric disorders. Further, educational material for health workers, general population and other stakeholders should be formulated. These are areas in which active cooperation among the South Asian nations is possible.
Policy and service development
Mental health policy and legislation is under development and in the stage of improvisation in most South Asian nations. A South Asian forum can be convened to discuss the experience with the current policies and legislations, which can be used to formulate new policies and legislations for the individual countries. Service integration with primary care is found to be more cost-effective in delivering mental health care. As shown in table 4, the integration is incomplete in most SAARC nations. India has successfully tried integration of services with primary care and is currently in the process of extension of such services to all the districts in the country through a decentralized program called the District Mental Health Programme. Such models can be used to develop similar programs in SAARC countries.
Human resources and infrastructure for mental health care is inadequate throughout the region. The resources needed for development of human resources is lacking in some countries. Other countries like India have centers of excellence with adequate facilities for training, which can be used for training manpower from other nations. Countries which have relatively better training personnel can share manpower with other nations to develop local training centers. Student exchange programs can be used to foster learning. Health workers and trainers from other countries can be trained through existing models in some countries like the District Mental Health Program in India.
Advocacy
Advocacy should be directed towards consumer, family, nongovernmental organizations; health and mental health workers; policy-makers, planners, and donors and the general population. There is a need for active involvement of various stakeholders including patients and caregivers. The mental health literacy of general population should be improved to improve treatment seeking. International agencies like the WHO, World Psychiatric Association etc. and non-governmental organizations can be involved towards this end. The South Asian nations can develop a common forum for promoting advocacy initiatives.
Research
South Asia is lagging behind in the field of mental health research due to various factors like lack of adequate financial support and infrastructure and poor collaboration among various health agencies (Trivedi et al., 2007). There is a paucity of service based research, an area where South Asian nations can collaborate fruitfully. Currently research evidence is based on Western data, which may not be applicable to this region. There is a need to develop and test service models which are applicable to the local scenario.
Active collaboration in research activities among South Asian nations is possible, especially in areas like service delivery, pathways to care etc. Some of the strategies that can be used to promote research in the region include:
1. Fellowships for training in research methodology can be started for training personnel from SAARC nations.
2. A regional forum to be formed to promote and fund young researchers, who carry out research which are more relevant to the local context.
3. A SAARC psychiatry journal can be formed to facilitate dissemination of research.
4. Regular SAARC Psychiatry Conferences can be conducted towards the same end.
Conclusion
South Asian nations, like the rest of the world suffer from a significant burden of mental illness. The region shares the same problems of poor resources, huge treatment gap and barriers to service development. It has been demonstrated that services can be scaled up in a cost effective manner in low income countries also. There is a need for active cooperation in the region for improving the current scenario. South Asian nations can complement each other in striving towards the goal of universal mental health care through the formation of proactive regional forum.
References
WORLD HEALTH ORGANIZATION. 2004. Global burden of disease project [Online]. Available: http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html [Accessed December 2010].
WORLD HEALTH ORGANIZATION 2005. Mental Health Atlas, Geneva, World Health Organization.