Raza-ur-Rahman ( Dow University of Health Sciences, Karachi. )
Mohammad Naim Siddiqi ( Sindh Institute of Urology and Transplantation (SIUT), Karachi. )
Syed Haroon Ahmed ( Jinnah Postgraduate Medical Centre, Karachi. )
After the 18th amendment in the constitution health becomes a provincial subject in Pakistan. Sindh Provincial Assembly took the lead and passed the Mental Health Act on 19th September 2013. On 10 April 2015, Sindh assembly passed an amendment that a person who attempts to kill himself or be accused of blasphemy should be examined by a psychiatrist and given treatment if found suffering from a mental illness. It is clear that the act is aimed to help in improving the delivery of mental health care and to protect the rights of mentally ill individuals. Will it meet its intended aims? We have discussed the challenges that lie ahead with special reference to Pakistan. Until we understand these challenges, we will not be able to propose the possible solutions to reach the intended goal of this Act and could avoid the failure of implementation of a similar law "the Mental Health Ordinance 2001".
Keywords: Mental Health Act, Mental illness, Pakistan.
According to Harvard Report (1996) on World Mental Health, presented to UN General Assembly, disability due to Mental illness account for about 28% of total disabilities world wide and 40% of these disabilities are preventable. By the year 2020 mental health problems would contribute 15% to the Global Disease Burden. The unipolar depression was predicted to rise from being the fourth to the second most disabling health condition in the world by 2020.1
Prevalent scenario of Mental Health in Pakistan
In Pakistan the burden of psychiatric morbidity has increased in recent years though there is no adequate epidemiological data documented account of mental disorders. It is based upon few studies showing high prevalence2 and has come into light because of increased awareness and ever increasing level of well recognised sources of stress in the current geopolitical and socio-economic situation of Pakistan. The major reasons suggested for this increase in prevalence of psychiatric morbidity are growing insecurity, terrorism, economical problems, political uncertainty, unemployment and disruption of the social fabric.3 In the absence of proper epidemiological data the computation of the burden of these disorders is difficult and the convention is to use the WHO epidemiological formula for the estimation of psychiatric problems in any given population. By this formula, 10% of any given population suffers from neuropsychiatric conditions and 1% from severe mental illnesses at any one time.4 Using that formula and estimating the prevalence of psychiatric morbidity in 200 million population of Pakistan, it is estimated that approximately 2 million people do suffer from severe mental disorders and 20 million suffer from some form of mental disorder. To deal with this burden of disease there are less than 500 psychiatrists available.5 That means one psychiatrist for 400,000 people. According to Mental Health Atlas 2005, there are only 0.24 psychiatric beds per 10,000 populations in both public and private sectors and only 0.2 practicing psychiatrists per 100,000 populations. This ratio of psychiatrists for the population is much lower than the neighbouring country like India where it is 0.4/100000.6 Almost all of the psychiatrists are serving in cities while bulk of the population is residing in rural areas. Even in big cities conditions are not very encouraging e.g. in 15 million population of Karachi, more than 1.5 million psychiatric patients are present. To take care of these patients 600 psychiatric beds and only 70 trained psychiatrists and few if any trained psychiatric nurses are available. Similarly mental health facilities in prisons across Pakistan are almost non-existent.7
Sindh Mental Health Act 2013
The passage of the Sindh Mental Health Act 2013 is a landmark achievement in bringing the mental health as one of the main public health issues. This act will contribute in protecting the human rights of mentally ill patients of Sindh. The previous main amendment in mental health law was done in 2001 when health was under federal administration. Although the Mental Health Ordinance of 2001 repealed a century old Lunacy Act of 1912 but it was not implemented8 due to lack of interest by policy makers, including development of supplementary documents like rules and forms.
The process of passage of the Mental Health Act by Sindh Parliament was preceded by enactment of Mental Health Ordinance by the care taker Government of Sindh in April 2013. The process of drafting and reviewing this legislative document involved extensive discussion and consultation with different national and international experts. The hindrances identified in implementation of Mental Health Ordinance 20019 were addressed in this Act. Rules and forms were developed which have been gazette notified in 2014.
Issues in Implementation of Mental Health Act
The new Mental Health Act will pose number of challenges to the Health and Auxiliary Services. These challenges are related to different areas that include; organizational system, human resources, social services, legal and judicial services, information systems and financial resources. These will be discussed one by one in detail.
1. Organizational System
In the public sector, the Mental Health Services are a part of the health care system and the Mental Health Units are organizationally part of the institutions providing health care services to the population. Within this curative paradigm the psychiatric facilities are extended to regional and district hospitals but there is no provision of psychiatric services at basic or rural health centres where bulk of the population reside. In the present health care system challenges will be faced in implementing the MHA because A) there is no organizational or structural representation of mental health within the Ministry of Health hierarchy B) In the pyramidal model of health care system starting with primary health care at the bottom, the referral process is inefficient and patients are usually taken by their families directly to tertiary or specialist hospitals, rather than to primary-care practitioners.10 C) the organization of health system in relation to psychiatry is not uniform e.g. a substantial proportion of the mental health services are provided by the private sector that stands as isolated units and have no operational link with Health Care System.11 D) community psychiatry is viewed as \\\'outreach\\\' services from psychiatric facilities and the application of public health principles to mental health services has not been tried. It is evident that monitoring the application of these principles through MHA will be a big challenge.
One of the solutions could be the formulation of a uniform mental health programme for Sindh province and fully integrate it into a decentralized general health care system. This will require lots of convincing and reshuffling. However the resultant change could enable the public and private sectors to provide equitable services to all who need assistance for their mental health needs.
2. Human Resources in Mental Health
A fully operational Mental Health Act depends on the availability and involvement of an adequate number of well-trained multidisciplinary mental health professionals. For a comprehensive and effective service that could also meet the intended goals of the SMHA, a multidisciplinary team approach is mandatory. This team should include psychologists, mental health social workers, occupational therapists, nurses and doctors. This team should be supported by mental health act administrators and interested and well-motivated legal practitioners. But as in most of the developing countries, in Pakistan as well, the focus of mental health service provision is on psychiatrists and psychiatric nurses, and even they are thin in number. Psychiatric Social Workers are an integral component of any well-established system that is unfortunately neglected.6 These psychiatric social workers are internationally recognised as the advocates for the protection of the human rights of people with mental disorders and ensure that people with mental disorders get what society has stipulated for them. But the supply of and the role of psychiatric social workers in the implementation of the Act, has not been explicitly addressed.
Psychiatric sub-specialties are another area that needs urgent but long term planning. Certain areas where the trained professionals are particularly scarce or non-existent are; Forensic psychiatry, Child and Adolescent, Learning Disability, Addiction psychiatry and Liaison psychiatry. Forensic mental health issues has interface with the judicial system that require special attention without which the full realisation of the potential of the Mental Health Act may be severely compromised. At the moment, there is no forensic psychiatrist in the country to provide this specialist input.
Presently the ministry of health does not adequately capture issues of the mental health workforce. A well-targeted campaign is needed to highlight the issue and to devise a human resource strategy which systematically addresses recruitment, retention and professional development of mental health workforce, within and outside the mental health sector.
3. Social Services
Mental health has never been a top priority in the overall health system of Pakistan Hence the present workforce and conditions of general social services in Pakistan is neither trained nor equipped with expertise to support the implementation of the Mental Health Act. This important aspect has already been highlighted in the discussion above.
Although the social services do provide input to physical rehabilitation, both at hospital level and in the community but such services for psychiatric patient are neglected. Somehow in the new Law, no consideration is given to the important area of psychiatric rehabilitation. One of the possible solutions could be to develop a close liaison between the Board members of the Mental Health Authority and the Social Services Directorate to work for an integrated model to make mutually beneficial frame work for social care provision and community rehabilitation needs of people suffering from physical or mental disorder. This must go in parallel to build and enhance the skills and expertise of the current social workers to deal with the special issues of the psychiatric problems or ideally until specialized psychiatric work force is ready to take charge.
4. Legal Issues
It has long been demanded that, the laws of Pakistan Penal Code (PPC) should be reviewed to cater the needs of mentally ill people e.g. decriminalization of suicide. Fortunately Sindh Assembly on 10th April 2015 has approved an amendment that a person who attempts to kill himself or be accused of blasphemy should be examined by a psychiatrist and given treatment if found suffering from a mental illness.
It is a welcome development but again points towards the issue of human resource, in this case the small number of psychiatrists, that has been addressed above. It also highlights another important area, i.e. the lack of a proper legal platform that can support the mentally ill patients so that the breach of their rights could be minimized. At present only few NGOs and lawyers working for human rights are advocating the rights of mentally ill patients.
Furthermore, in Pakistan the teaching of law, related to health, in law colleges is neglected As a result, the lawyers are not well versed with knowledge of health related issues while the mental health issues are almost totally ignored. In the absence of the lawyers trained in health law, it will be difficult to implement the mental health act in its true spirit.
Similarly mental health cases would need formation of tribunals. For higher level of independence and impartiality of these tribunals, it would be ideal if these tribunals are formed and regulated by the Judiciary. But in a country where the judicial system is already under a lot of pressure for quick decision and disposal of pending cases it could be difficult especially when high turnover of complaints from detained patients, is expected.
Therefore an urgent dialogue is essential between representatives of mental health profession and legal fraternity to ensure the availability of trained mental health professionals and advocates for assistance of mentally ill patients. Establishment of such facilities in Sindh is strongly recommended for better implementation of Mental Health Act.
5. Dissemination of Information
The first step of success for any campaign or strategy is to raise the awareness of the issue; in this case the Sindh Mental Health Act and the benefits or implications of its implementation to different sections of the society. It is known that in spite of the low literacy rate,12 poverty13 and poor basic facilities,14,15 mobile phone and internet usage is disproportionately high in Pakistan.16 Advantage of this facility can be taken for dissemination of information about the rights of mentally ill patients and the protection of their rights with special reference to Mental Health Act. Similarly social media has recently shown its impact globally and at our national level. Use of this powerful medium to familiarise the general public, especially the younger generation could be a cost effective way of dissemination of information about mental health issues.
Medical students (the future doctors and Psychiatrists), should be made familiar about the existence and appropriate use of the Act for the benefit of the most marginalized and stigmatized section of the society. Inclusion of this law in the medical syllabus could be one solution and arranging workshops and training sessions for different stake holders could be another step. A road map could be drawn that how and at what stage should the first cycle of such an awareness campaign be completed or the finish of the training session etc. We must be cognisant of the fact that such a campaign is an ongoing process and every completed cycle will provide a new insight and opportunity for further improvement.
A central authentic system to address the queries of mental health professionals or people interested in the rights of patients suffering from mental illnesses may be developed. Such a system could address, to some extent, the additional burden on the staff to follow legal requirements under the Act. Transition from the current information system to a robust and well-functioning information system is perhaps a long way off in the current Pakistani scenario. However whenever we are ready, we will have to be aware of the pitfalls of such a transition.17-19
6. Financial Issues
At present the health sector budget allocation for mental health is less than 0.4% versus the WHO-recommended 15% that is disproportionately a small allocation even when compared with similar countries falling into same economic band and having overall limited resources.6,20,21
The implementation of Mental Health Act will launch several new activities in mental healthcare delivery system. These activities would require funding to make it workable e.g. the establishment of Sindh Mental Health Authority and Board of Visitors to conduct periodic inspection of mental health facilities. Similarly, additional funding would be required for training of professionals and appointment of mental health tribunal judges, lawyers representing patients and logistics to run the system.
In this scenario, when the mental health budget is clearly grossly insufficient for even the current meagre services, the financial needs require to be re-examined from different viewpoints.
The argument that Mental Health is not only a \\\'Health Issue\\\' but it also has \\\'social\\\' and \\\'occupational\\\' component does carry a lot of weightage.
Therefore, a) We should remind the legislators of the current Sindh Mental Health Act their responsibility to provide the necessary resources (finances) for implementation of the act and b) Build a case that it should not be the sole responsibility of the health department to finance mental health care but the Social Welfare department, Finance department and Local Government should also contribute and take their share of responsibility.22
Although the passage of Mental Health Act is a big achievement for all those who untiringly continued their efforts in spite of many hurdles, yet possibly another bigger challenge is its implementation. We have tried to examine different issues and their potential solutions but one fact is very clear that without the will, motivation, understanding, cooperation and support of different stake holders, the law\\\'s implementation in its true letter and spirit would be extremely difficult. However we are hopeful that Pakistan will not have to wait as long as it had to for its acceptance.
The province of Sindh has another opportunity to lead the country again, by showing that Sindh Assembly has not only passed the bill but has allocated the necessary resources for its implementation
This paper is dedicated to the memory of Professor Musarrat Hussain, former Chairman Psychiatry & Director Medical Education, Jinnah Postgraduate Medical Center, Karachi, who passed away on 3rd August 2011.
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