WITH a population of 220 million and rising, Pakistan is currently the world’s fifth most populated country. Demographically, it is among the youngest: 64 per cent of the country’s population is under the age of 30. Already socioeconomically vulnerable, the disruptions ushered in by the Covid-19 pandemic have laid bare the state of mental health challenges and inequities across the country. They have also underscored just how far behind Pakistan is from where it needs to be on mainstreaming mental health as part of the national agenda. Despite being a signatory to the Mental Health Action Plan 2013-2030 by the World Health Organisation, Pakistan has until now made little progress either in implementing legislation or addressing the severe dearth and inequitable distribution of mental health resources and non-existent provisions for psychosocial support across the provinces.
This is why a recent move by Pakistan’s federal Ministry of Planning, Development and Special Initiatives to launch a Mental Health & Psychosocial Support (MHPSS) initiative, funded by Unicef, as part of the country’s emergency response to Covid-19 is important. Run by a Mental Health Coordination Unit set up by the Ministry of Planning, Development and Special Initiatives, the project marks the first instance of an evidence-driven, rights-based model of MHPSS response to public health emergencies in Pakistan. This model is designed to be scalable and sustainable, while taking into account local needs and resources.
The project’s objectives are to raise public awareness for psychosocial well-being and address stigma and discrimination of infected populations; support front-line responders, and integrate MHPSS in response activities; provide psychosocial services to the most vulnerable population groups including women and children at risk, bereaved families, and people with disabilities; and facilitate mental healthcare to those suffering from mental disorders. The plan is informed by a rapid needs-assessment that was carried out earlier in the year to identify mental healthcare needs as well as existing resources and gaps across the spectrum of care in Islamabad Capital Territory.
This new initiative is critical for several reasons. Firstly, it marks the first serious national attempt to prioritise mental health, despite many ad hoc efforts to increase investments in social and developmental infrastructure in recent decades. The last major milestone was exactly two decades ago in 2001, when Pakistan promulgated its first mental health legislation repealing the Lunacy Act 1912.
Hopefully, the government’s mental health initiative will prove to be a game changer.
Secondly, mental health problems are complex and closely linked to biological, socioeconomic, political, and cultural determinants. For any serious effort to address mental health problems, inter-sectoral collaboration with the country’s ministries of health, human rights, education, interior, law and justice, and disaster management authorities is essential — domains which have traditionally operated in silos without significant coordination. For this reason, the new MHPSS plan is to be implemented through the formation of a Covid partners forum comprising public entities including line ministries, academic departments, the National Disaster Management Authority, humanitarian agencies, media, social enterprises etc.
Thirdly, because of Pakistan’s devolved federal structure, health is a provincial subject. Even if it is able to plan a national response, the mandate of the federal ministry of health doesn’t extend to the provinces. This has meant that until now, each province has struggled in one way or another with a dearth of mental health expertise and resources. The new plan, which falls under the Ministry of Planning, aims to correct this. In addition to the ministry’s comparative advantages, both budgetary and capacity for strategic planning at a national level, as a federal ministry it is well placed to offer a template for its provincial counterparts to easily implement.
Fourth, the public health crisis brought about by the pandemic has both sapped existing healthcare resources and magnified Pakistan’s mental healthcare needs by many folds. It has made clear that the task of meeting mental ill health challenges must go beyond just finding simplistic biomedical solutions for mental disorders, and include providing psychosocial support in response to national emergencies, humanitarian crises, and conflict. The exclusive mandate of the ministry to identify an overlooked area that needs attention and launch it as a special initiative is also an opportunity to address this multifaceted challenge.
So what does the new initiative look like? It comprises an electronically integrated system that will build the capacity of a mental health workforce and set up referral links to offer therapeutic interventions at four tiers or rungs, based on the principle of task shifting. At the first tier, members of the community will be trained to provide basic psychological support and identify/refer people with mental health problems who might need further help. At the second tier, a team of counsellors will provide psychosocial support services to front-line responders and other vulnerable groups suffering from stress-related conditions. At the third tier, a team of consultants comprising of medical doctors and clinical psychologists will be trained to provide services for common mental disorders in primary care. Finally, at the fourth tier, a team of mental health specialists will provide consultation and facilitate referral pathways to other services.
Training resources used in the initiative will be evidence-based, adapted to local needs, and be made available in both English and Urdu. Trainings will be accredited and offered on-job supervision. The web-based integrated system, which will also allow for data consolidation and reporting, will include a project web portal integrated with a Learning Management System and three applications which are being developed on the content adapted and translated from standard international training guidelines to provide services.
If this pilot succeeds in engaging the community, builds the capacity of mental health professionals and develops the much-needed inter-sectoral collaboration, it might be a solution to be replicated in Pakistan’s other four provinces as well.
Asma Humayun is senior technical adviser, MHPSS, Ministry of Planning, Development and Special Initiatives. M. Asif is chief health, Ministry of Planning, Development and Special Initiatives.
Published in Dawn, July 15th, 2021