International Journal of Current Medical Science and Dental Research (IJCMSDR) Volume 1 Issue 1 ǁ May-June 2019 ǁ PP 18-22 ISSN: 2581-866X || www.ijcmsdr.com
Mental Health in South Asia:Resource Scarcity and Systemic Neglect 1,
Dr. Anwar Islam
Visiting Professor, Department of Public Health, North South University, Dhaka, Bangladesh
ABSTRACT: In population size India, Pakistan and Bangladesh comprising the Indian sub-continent are the largest in South Asia with a combined population of 1.66 billion. Although widespread poverty, natural disasters, environmental degradation and rapid urbanization make the population of these countries most vulnerable to health hazards, they spend little money as a percentage of their Gross Domestic Product (GDP) on health care. While India spends only 4.7% of its GDP on health, Pakistan and Bangladesh spend even less 2.6% and 2.8% of their GDP on health respectively. Resources dedicated to mental health are far lower. The paper critically examines the pattern of mental health resources (human, financial and facilities) in these South Asia countries with a view to highlight the plight of the mentally ill. This may help explain, partially at least, the continuing systemic neglect faced by mental health in these South Asian countries comprising more than 23% of the global population.
I.
INTRODUCTION
In many countries, mental health or psychosocial health is often neglected within the broader health care system. It attracts little financial or human resources and institutional recognition. This is often true for many developed countries too. For example, globally in 2014 there were only 7.7 nurses working in the mental health sector per 100,000 population. On the other hand, in 2014, 45% of the world’s population lived in a country with less than 1 psychiatrist per 100,000 population (World Health Organization, Global Health Observatory). Needless to point out that basic human resources for mental health is grossly unevenly distributed across the world. In 2014, for example, Afghanistan had 0.01 psychiatrists working in the mental health sector per 100,000 population. The country had 0.11nurses working in the mental health sector per 100,000 population. The corresponding figures for Bangladesh in 2014 were 0.13 and 0.27 per 100,000 population respectively. On the other hand, in 2014 the United States had 12.4 psychiatrists working in the mental health sector per 100,000 population. It had 4.25 nurses working in the mental health sector per 100,000 population. The corresponding figures (2014) for the United Kingdom were 14.63 and 67.35 respectively. The other two South Asian countries – India and Pakistan – also suffers from acute shortage of key human resources for mental health. In 2014, India had only 0.3 psychiatrists working in the mental health sector per 100,000 population. Surprisingly, India also had a severe shortage of nurses working in the mental health sector (only 0.12 nurses per 100,000 population. The corresponding 2014 figures for Pakistan were 0.31 and 15.43 per 100,000 population. The disparity between the developed and developing countries in terms of human resources for health persists even if the volume of non-specialized physicians is considered. For example, in 2015 India had 6 physicians per 10,000 population and Pakistan had 7.4 physicians per 10,000 population. The corresponding figure for Bangladesh was only 2.6 per 10,000 population. On the other hand, in 2015 the United States had 23 physicians per 10,000 population. The corresponding figures for the United Kingdom and Canada were 22 and 21 per 10,000 population respectively. Findings: It is important to better understand the underlying factors for such acute scarcity of human resources in the mental health sector in low- and middle-income countries. Table-1 presents some of these figures for a selected number of low-income as well as high-income countries. The Table-1 clearly underscores the gross disparity in the distribution of key mental health related human resources across developed and developing countries.
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Mental Health in South Asia: Resource. Table-1 Human Resources per 100,000 population Working in the Mental Health Sector, 2015
Source: Global Health Observatory: World Health Organization, 2015 Among three the South Asian countries, as Table-1 clearly shows, Bangladesh suffers most from the most severe shortage of key mental health related human resources. It has only 1.3 psychiatrists for a million people and 1 psychologist for about 3 million people. On the other hand, both India and Pakistan have 3 psychiatrists for every 1 million people. Interestingly, while India has only 11.2 nurses in the mental health sector for 1 million people, Pakistan had 154 nurses in the mental health sector for every 1 million people. Understandably, the volume of human resources for mental health are much higher in developed countries. For example, in Canada there are 134 psychiatrists and 474 psychologists per million population. The United Kingdom, on the other hand, has 146 psychiatrists and 128 psychologists per 1 million population. The corresponding figures for the United States are 124 (psychiatrists) and 296 (psychologists) per 1 million people. Even among the developed countries, Canada has significantly more social workers per 1 million population (1,178) than others. The corresponding figures for the United Kingdom and the United States are only 128 and 296 respectively (per 1 million population). It is important to look at the institutional and financial resources committed to mental health services in the three South Asian countries under review. According to a recent WHO report (WHO 2015), “global spending on mental health is still very low. Low and middle-income countries spend less than US$ 2 per capita per year on mental health, whereas high-income countries spend more than US$ 50”. Moreover, most of the spending is earmarked for mental hospitals, “which serve a small proportion of those who need care. High-income countries still have a far higher number of mental hospital beds and admission rates than low-income countries at nearly 42 beds and 142 admissions per 100,000 population” (WHO 2015). In the three South Asian countries under focus (Bangladesh, India and Pakistan), expenditure on health is particularly low. In 2013, for example, Bangladesh had a per capita health expenditure of only $32. The corresponding figures for India and Pakistan were $61 and $37 respectively (World Bank, 2014). Most estimates indicate that these countries spend about 5% of their financial resources for health on mental health (WHO, World Mental Health Report 2011). It is far lower if only the government expenditure is considered. In Bangladesh, for example, mental health services account for only 0.5% of total government expenditure oh health care (WHO and Ministry of Health and Family Welfare, 2007). An overwhelming proportion of these
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Mental Health in South Asia: Resource. funds (67%) go towards hospital-based mental health care, while only 33% of them go towards communitybased mental health services. Institutional facilities for mental are also scarce in these countries. For example, India with a population of more than 1.3 billion has a total of only 443 mental and/or psychiatric hospitals.But six Indian states in the Northern and Eastern regions of the country with a combined population of 56 million are without a single mental hospital (Anuradha, 2016). Even NGOs involved in providing mental health services are largely concentrated in the Southern and Western regions of the country and especially in large urban centres. According to the author, the District Mental Health Program (DMHP) in India – the primary vehicle through which mental health services are provided across the rural population - covers only 200 districts so far. Due to restricted funding, human resource scarcity and lack of motivation on the part of the service providers at all levels, the effectiveness of the DMHP varies widely across the country. “In practice, DMHP is largely limited to psychiatric outreach clinics in a few primary healthcarecentres, and more than 60 per cent of people with mental disorders access care directly at a district hospital, rather than the primary healthcare centres” (Anuradha, 2016). The Indian mental health system also suffers from a severe shortage of funding. For example, in 1985-90 the National Mental Health Program (NMHP) had a budget of only Rupees 10 million. Funding for the NMHP increased substantially over the next two five-year plans (1997-2007). Nevertheless, the proportion of total health budget that is allocated to mental health remains notoriously low. For example, in 2012-13 only 1.3% of the Ministry of Health and Family Welfare expenditure was spent on the National Mental Health Program (Lancet, 2016). Bangladesh, on the other hand, has only one 500-bed public mental hospital established in 1957. More recently in 2000, a National Institute of Mental Health with 50 beds has been established in the capital city of Dhaka. There are 50 outpatient mental health facilities in the country. Perhaps it would useful to put the summary findings of the 2007 WHO/Ministry of Health and Family Welfare study on the Mental Health System in Bangladesh. “Bangladesh's mental health policy, strategy and plan were approved in 2006. In 2005, money spent for mental health services was less than 0.5% of the total national health expenditures. A national survey in 2003-2005 reported 16.05% of the adult population in the country suffering from mental disorders. No mental disorder is covered by social insurance, no human rights review body exists in the country to inspect mental health facilities, and no specific mental health authority in the country has been established. “There are 50 outpatient mental health facilities but no day treatment facilities. There are 31 community-based psychiatric inpatient units, 11 community residential facilities and one 500 bedded mental hospital in the country. “The density of psychiatric beds, psychiatrists and nurses in or around the largest city is 5 times greater than the density in the entire country. The total number of human resources working in mental health facilities or private practice per 100,000 population is 0.49.Only a small percentage of all health publications in the country are on mental health. “Next steps for improving the mental health system include strengthening community mental health facilities and the provision of mental health in primary care, as well as increasing mental health human resources” (WHO/MOHFW, 2007). Acute scarcity of resources also has negative impact on the mental health services in Pakistan. In an article published in the national daily the Dawn, one scholar noted that “only 400 psychiatrists and 5 psychiatric hospitals exist within the entire country (Pakistan) for a population exceeding 180 million. This roughly translates to an alarming psychiatrist-to-person ratio of 1 to half a million people” (Mahmood, Arif, 2014). It is evident that each of these three South Asian countries – Bangladesh, India and Pakistan – suffer from severe scarcity of resources for mental health. They lack adequate number of key human resources for mental health including psychiatrists, nurses, social workers and psychologists. Institutional facilities – mental hospitals, psychiatric outpatient clinics and community-based primary health care centres – are also scarce in these countries. Most importantly, these South Asian countries continue to allocate meagre financial resources for mental health programs and services. In short, mental health does not receive the attention that it deserves. It is neglected by the planners and policy makers. The Ministry of Health in these countries often does have a dedicated focal point with adequate bureaucratic authority and power for mental health. Why this neglect? It is imperative to better understand the societal factors underlying such neglect of the mental health system.
II. DISCUSSION
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Mental Health in South Asia: Resource. Societal values, beliefs, attitude and behavior are primarily responsible for such utter neglect of the mentally ill and, thereby, the mental health system. In Bangladesh, India and Pakistan mental illness is generally not considered as an illness that needs to be treated like that of high blood pressure or coronary heart disease. In these countries, mental illness is culturally defined not as an illness but as a behavioral anomaly caused by possession by the spirits. Being possessed by the spirits, the mentally ill is taken not to a physician or psychiatrist but to the spiritual healer – in most cases the religious leader. In a study reported by Dr. Thara, psychiatric patients in Chennai, India were found to the chained to trees in the shrine of a religious personality. Most interestingly, while the psychiatric patients were mostly Hindus the shrine was that of locally highly respected Muslim religious leader (Thara, et.al., 1998). Throughout India thousands of psychiatric patients are left wandering in the shrines of famous Islamic religious personalities with their elaborate establishments in Azmer, Delhi, Sri Nagar and Ahmedabad. Similarly, in Pakistan the shrines of famous Islamic religious leaders in Karachi, Lahore, Peshawar, or Rawalpindi. Bangladesh is no exception in this regard. The mentally ill in large numbers flock to many shrines of Muslim religious leaders in Dhaka, Sylhet, Chittagong, Rajshahi and Mymensingh. It would be misleading to say that this phenomenon is limited to shrines of Muslim religious personalities. Shrines of Hindu Sikh as well as Christian religious personalities are also home to large number of psychiatric patients. With such societal beliefs, it is not surprising that the mentally ill face social stigma and exclusion. While stigma has many dimensions, its most paramount consequence is that it severely limits an individual from gaining complete social acceptance with devastating consequences. Without social acceptance, the opportunity to be gainfully employed and earn a livelihood becomes critically limited for the mentally ill. Social exclusion also makes it difficult to get married, have and retain friends, socialize with others in the community and be part of a well-functioning social milieu. Social stigma discourages many to accept those suffering from psychiatric disorders as friends or colleagues. Social stigma is often so encompassing that the mentally ill often find themselves totally isolated and devoid of social connectivity. Conclusions and Recommendations: Societal values and beliefs shape the attitudes of people towards the mentally ill. As individuals suffering from psychiatric disorders are viewed as sub-humans, the society in these countries foster an attitude of neglecting the civil and human rights of the mentally ill. With such an attitude people become immune to the daily sufferings of the mentally ill.In other words, the societal values and beliefs regarding the mentally ill in these South Asian countries give birth to a stereotype that defines them as “socially deviant” and “unacceptable”. Stereotypes are always “oversimplified” ideas used to categorize people that are different. Stereotyping the mentally ill also means having pre-conceived views about them based on prejudice or negative attitude. Prejudice paints all the mentally ill with the same brush leading to derogatory stereotyping. Stigma, prejudice and derogatory stereotyping underlay the discriminatory behavior towards the mentally ill. In India, Bangladesh and Pakistan the mentally ill face continued discrimination in terms of jobs, housing, and socialization. Such discrimination against those suffering from psychiatric disorders is easily discernible across these South Asian countries whether it is mild depression, post-traumatic stress disorder, anxiety or the more serious schizophrenia. The societal stigma, stereotyping, prejudice and discrimination endured by the mentally ill in these South Asian countries are also reflected in the official policies and programs. Low allocation of resources by the Ministry of Health as well as other authorities underscore the official neglect of the mentally ill. Along with extremely limited financial resources, these countries have few policies or programs serving the mentally ill. Often official policies are there to protect the rights of the mentally ill but they are seldom enforced. The official neglect of the mentally ill is also reflected in the absence of a powerful authoritative body in these countries entrusted with the task of overseeing such policies and programs. It is imperative that concerted efforts are undertaken to forcefully address the societal stigma, prejudice and discrimination being suffered by the mentally ill in these South Asian countries. Establishment of a powerful authority within the Ministry of Health with legislative mandate to comprehensively serve the people with psychiatric disorders is essential in this respect. Needless to say, such an authority must also have adequate resources – both human and financial – to accomplish its mandate. Non-government Organization as well as other social advocacy groups must also be mobilized and empowered to serve the mentally ill. Most importantly, social awareness about the mentally ill and their rights, privileges and responsibilities must also be raised so that social stigma, prejudice and discrimination against them can be effectively addressed.
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Mental Health in South Asia: Resource.
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