RECENTLY, a much-needed round-table conference on mainstreaming mental health and incorporating it into the public discourse was held by the Planning Commission. The deliberations focused on the need to promote positive mental health, prevent psychosocial adversity, and address the ever-growing burden of disease and disability caused by mental, neurological and substance-use disorders.
A concerted national plan to address the population’s mental health needs is still non-existent, despite ad-hoc efforts that have been made over the past four decades. Amorphous landmarks include a rudimentary mental health policy formulated in 1997, negligible allocation of the health budget (barely 0.4 per cent), ineffective mental health legislation, and interim mental health programmes such as the federal initiative for psychosocial support that was launched in the aftermath of the Army Public School massacre in 2014.
Investing in mental health is crucial for any country striving for sustainable development. Mental health should not just be an overarching public health priority. It has far-reaching consequences for a state’s economic, social and human capacities. According to present estimates, 20pc of Pakistan’s population may be suffering from mental disorders. This is a figure that includes children and adolescents. The irony is that while affordable treatment is available, 80pc of patients do not receive it.
It is well established that poor mental health leads to decreased productivity, a heavy price that is paid in terms of both health and economic performance. Recent research conducted by Aga Khan University shows that high productivity losses and the non-medical consequences of mental illnesses are far greater than the medical costs. It is estimated that the overall cost of mental disorders in Pakistan is over Rs250 billion per annum.
Policy and legislation are two avenues that need to converge for mental healthcare and services in Pakistan to begin to improve. A comprehensive mental health policy should be able to address critical issues such as the promotion of mental health throughout the country; access to quality mental healthcare; development of robust procedural protections; protection of human rights; and integration of persons with mental disorders into the community.
Policy and legislation need to converge for mental healthcare and services to improve.
Mental health legislation can help achieve these goals by providing a legal framework for implementation and enforcement. Conversely, legislation can also be used as a framework for policy development. Mental health systems are being developed in other countries in South Asia such as India, Afghanistan and Nepal, where legislations were enacted in 1987, 1997 and 2006 respectively.
We are now at a stage where the Pakistani government needs to undertake a review of the fundamental interface between legislation and policy. Since the passage of the 18th Amendment, the provinces are still struggling to formulate effectual mental health policies and legislations. In the cases of the Sindh and Punjab mental health acts (2013 and 2014 respectively), the Mental Health Ordinance (MHO) of 2001 was used as a background document with limited deviation. Had there been documented facts showing disparity in the needs and resources of different regions, there might have been an argument for provincial laws and jurisdiction. In the absence of this, a federal coordinating and regulatory strategy is likely to be less nominal. Pakistan faces a severe dearth of specialised mental health resources, and assembling expertise centrally for advocacy, policy decisions, capacity building, and inter-sectoral collaboration is vital.
It is also necessary to examine the barriers that have impeded significant reform, despite the fact that the Federal Mental Health Authority was convened following the MHO. Lack of political will, inept mental health leadership, dysfunctional institutions and inadequate resources have made it difficult to implement reform. In the absence of a well-developed system, it might be more realistic to scale down the mandate and to focus on prioritising the agenda in distinct phases. Keeping in mind provincial capacities, legislation must allow some tractability to condition the larger goals into smaller and practically more achievable steps. There is certainly a strong case to be made for focusing on building a mental health system rather than setting up resource-driven processes for accountability.
Any comprehensive legislation should aim to develop services for the integration of mental health in primary care, enhance mental health resources, protect the rights of the mentally ill, and establish specialised services for vulnerable segments of the population including women and children, prisoners, and people with disabilities. Had the MHO been effectively implemented, there would have been periodic forensic assessments and treatments offered to mentally disordered prisoners including Imdad Ali, and it would have saved a judgement based on the speculative interpretation of the legislation whereby the Supreme Court upheld Ali’s death sentence on Sept 27 before agreeing to a medical board assessment on Nov 14.
The existing psychiatric services are mostly limited to clinical aspects at the tertiary care and are presently maxed out.
An average doctor is hardly cognisant of promotive, preventive or therapeutic aspects of mental health. To a large degree, this is the result of not recognising psychiatry as an independent core subject to be examined at the undergraduate level.
Furthermore, there is a dire need to build up the capacity of primary healthcare personnel to promote positive attitudes, address widely prevailing psychological distress and implement early interventions for common mental disorders.
We also need to reduce the gap between public healthcare and the services provided by humanitarian agencies. The latter can be a critical resource for supporting refugees, victims of natural disasters, conflicts and violence. Last but not least, specialist services for children and adolescents, substance abuse, learning disabilities and forensic psychiatry are vital.
Mental health remains highly stigmatised and neglected in Pakistan. Most developed countries devote 5pc of their health budgets exclusively to mental health. The Planning Commission’s efforts to form a mental health task force and propose effective strategies to achieve the goals highlighted here are, therefore, a step in the right direction. It is time to make mental health a national priority.
The writer is a consultant psychiatrist.
Published in Dawn November 19th, 2016