Amin A. Muhammad Gadit ( Discipline of Psychiatry, Memorial University of New found land, Canada. )
Mental health policy is an essential and powerful tool for the promotion of mental health in any given population. Despite wide recognition of the importance of mental health policies, data collected by W.H.O. reveal that 40.5% of the countries have no mental health policy.1 Does Pakistan have a clear mental health policy? Local literature search gives very little information about the policy. The national health policy of Pakistan concentrates on poverty alleviation, priority attention to primary and secondary sectors of health to replace the earlier concentration on tertiary care and seeing good governance as the basis of health sector reform to achieve quality care. The mental health policy was first formulated in 1997 which addressed issues of advocacy, promotion, prevention, treatment, rehabilitation and intersectoral collaboration. It envisaged to train primary care providers, to establish resource centers at teaching psychiatric hospitals and detoxification centers. There was provision for crisis intervention and counseling services, special facilities for mentally handicapped and up gradation of large mental hospitals. The allocated mental health budget is 0.4% of total health care expenditures.2 As such the policy for mental health is not comprehensive and has multiple lacunae.
Pakistan has a huge burden of mental health problems which has been reported on numerous occasions. However, in terms of a clear mental health policy, we come across dilemmas. In order to understand the situation, it is important to look into the grim situation of low manpower resources, unidentified population needs, low priority to mental health, low political will for developing mental health services especially in rural areas, non-consultative attitude of government with the private and voluntary sectors and the relative indifference towards mental health related development by donor international agencies except the W.H.O. Little is heard from government in terms of initiatives towards mental health promotion. The current five year plan, describes about the possible move forward towards mental health promotion in the following way:
10th Five Year Plan-2005-10
The plan aims at working towards: adoption of biopsychosocial model, integration of mental health in health care at all levels, public-private partnership, formation of bilateral links between the teaching hospitals and the peripheral units, the public health approach to health care and participation of the public representatives. Some strategic themes also include: man power development, public education and awareness, de-stigmatization through promoting mental health literacy, service development and provision, development of "Mental Health Friendly Hospitals", facilities for substance dependent persons, development of sub-specialties like child, old age and forensic psychiatry, development of a national institute of Elderly Health and setting up of crisis centers through organized multi-sectoral collaboration.3
Development of the mental health policy1
It is important to understand the dynamics involved in mental health policy development as it has its complexities. The mental health field is affected by many policies, standards and ideologies that are not necessarily directly related to mental health. While formulating such a policy, it is necessary to consider the social and physical environment in which people live along with ensuring intersectoral collaboration. There are recommended steps by W.H.O., for developing a policy: Step 1: gathering information and data based on population needs which can be extrapolated from prevalence and incidence studies, Step 2: gathering evidence for effective strategies by reviewing the local and international literature and visiting local services, Step 3: consultation and negotiation by listening to various stake holders and to make proposals that blend their different views with the evidence derived from national and international experience. Step 4: exchange with other countries in terms of experience sharing in order to learn about both the latest advances in more developed countries and about creative experiences and lower cost interventions in less developed countries. Help from international experts is also worthwhile. Step 5: deals with setting of principles and objectives aiming at improving the health of population, responding to the people's expectations and providing financial protection against the cost of ill health. Step 6: Involvement of other sectors like: financing, legislation and human rights, organization of services, human resource training, promotion, prevention and rehabilitation, essential drug procurement and distribution, advocacy, quality improvement, information systems, research, evaluation of policies and services and intersectoral collaboration. Finally in step 7: to identify the roles and responsibilities of different sectors like: governmental agencies (health, education, employment, social welfare, housing, justice), academic institutions, professional associations, general health and mental health workers, consumer and family groups, providers, non-governmental organizations (NGOs) and traditional health workers. Once these steps are followed, a proper mental health plan can be developed stepwise culminating in implementation and subsequent evaluation.
Are the steps being followed?
Ironically, Pakistan has a dearth of prevalence and incidence studies as research has not been an important and strong component among the health professionals.4 There are hardly any organized national studies on mental health morbidity, the information management system is deficient and there is no compulsion on hospitals to send vital statistical information to the central bureau of statistics and hence figures about mental diseases are not easily available. The current figures which are frequently quoted are because of the efforts of few devoted researchers. The information about existing services is not fully available with the government and hence in their citations, the government would usually mention the work of one department in Rawalpindi and would normally ignore any other source of information. There is an incomplete list of stakeholders with the government and hence it is deprived of the vital information in connection with services and individual contributions. There is 0.4% mental health budget which is grossly insufficient and there is no health card or health insurance through the courtesy of government. The involvement of other sectors is not in full potential and their expected role is ill defined. Under the circumstances, despite a tall claim has been made in the country profile report produced by W.H.O., the question remains whether there is a mental health policy? The dearth of mental health research negates the existence of any such policy as it is essential for a proper mental health policy to utilize the health research findings.5 To make a modest beginning, it is worth exploring the 'Newfoundland provincial policy framework model’.6 Producing show-case documents just for the sake of creating pseudo-impression will lead us to nowhere as it is high time when mental health should be taken seriously.
1. www.who.int/entity/mental_health date accessed: 27/12/2006.
2. W.H.O. Mental Health Atlas, 2005: Country Profile: Pakistan, p: 2.
3. Government of Pakistan. Planning Commission. The report of the subcommittee on Mental Health, Substance abuse and the Health of the elderly. 10th Five-Year Plan: 2005-10, p: 1-27.
4. Gadit, A. Mental health research in Pakistan and the developing world. J Coll Physicians Surg Pak 2006, 16 : 169-170.
5. Hanney, S R. Gonzalez-Block, M A, Buxton, JM, Kogan, M. The utilization of health research in policy-making: concepts, examples and methods of assessment. Health Research Policy and Systems 2003, 2, 1-54.
6. Government of Newfoundland and Labrador. Working together for Mental Health-a provincial policy framework, October 2005, p: 1-24.