THE World Health Organisation (WHO) launched a landmark World Mental Health Report last month. The report is critical in terms of the evidence it provides for global mental health burden as well as the strategies it recommends for transforming mental healthcare in developing countries such as Pakistan.
The report reinforces, yet again, the fact that mental healthcare is not just a basic human right, but indeed a vital requirement for the economic development of any country. Sadly, while many countries have made considerable progress since the last World Mental Health Report in 2001, Pakistan still lacks a mental health policy, rights-based mental health legislation, and a comprehensive plan to strengthen existing services.
In the week following the report’s publication, this newspaper reported that in less than six months, at least 15 young people had taken their own lives in Gilgit-Baltistan. In an insightful statement, the chief minister of GB observed: “The youth are the future of our nation and its most precious asset. The prevalence of suicide among them is a matter of great concern to all. Hence we should work together to eradicate the menace from our midst. Otherwise posterity will not forgive us.”
The situation reported is neither new nor limited to GB. Mortality associated with poor mental health is only the tip of the iceberg. It is known that mental disorders are also the leading cause of ‘years lived with disability’ (also referred to as YLDs). Globally, one in eight (over the age of 10) suffer from a mental disorder, and this burden tends to rise to approximately one in five in countries that face humanitarian challenges. And Pakistan’s ongoing economic, political and environmental challenges only compound the population’s high risks for mental health.
Internationally, there is an encouraging movement to support the cause of mental health.
On paper, Pakistan is committed to meeting the Sustainable Development Goals, including SDG 3.4 that is related to the burden of non-communicable diseases and mental disorders; the Comprehensive Mental Health Action Plan 2013-2030 by the WHO; and a National Vision 2025 to improve the health of all citizens, including those who are the most vulnerable. However, mental health deserves to be prioritised in a healthcare system that is struggling to respond to the challenges of the pandemic, overpopulation, polio and tuberculosis. Psychosocial support for mental wellbeing can and should, in fact, be an integral element for a comprehensive response to all public health challenges.
While the provinces have the mandate and authority (in terms of human resources, infrastructure development and financial resource allocation) to develop and implement localised health policies, there has been a realisation that developing capacity to respond to their population’s mental health needs is important. The perpetuation of the status quo owes in large part to, inter alia, the absence of technical expertise and the shortage of cost-effective, tangible solutions.
To prevent and control mental disorders, the UHC Benefit Package consists of the Essential Package of Health Services at five unwieldy levels: community level, primary healthcare centre, first-level hospital, tertiary hospital and population level. Ensuring basic mental healthcare to 30 million deserving candidates is by no means easy. This task needs a major multisectoral undertaking to engage local communities, build primary healthcare staff capacities through training and supervision to treat common mental disorders, address a critical data gap that exists because of a defunct health management information system, strengthen specialist services at the district level and develop an effective referral mechanism to specialist services.
There are avenues of hope. Tasked with directing a long-term vision for the country, the Ministry of Planning, Development and Special Initiatives formulates a broad sectoral policy framework and undertakes strategic planning. It also has the mandate to identify an overlooked area that needs attention and launch it as a special initiative. In 2021, as part of the country’s emergency response to Covid-19 in 2021, and supported by Unicef, the ministry launched a Mental Health and Psychosocial Support (MHPSS) initiative, to develop and test a digital, multilayered model for mental healthcare.
Driven by evidence, this rights-based and scalable model took local needs and resources into account, and was designed to be integrated with a telecom solution for a support helpline. To build the capacity of a mental health workforce, internationally recognised training resources, including the mhGAP guidelines by the WHO, have been contextualised and translated for Pakistan. Under the model and as a pilot in Islamabad Capital Territory, a team of 10 mental health specialists was trained to strengthen existing services and supervise primary healthcare staff through training.
Furthermore, 20 clinical psychologists were trained as part of the model to support stress-afflicted populations, even remotely if required. Because of the use of digital technology, including a learning management system and three custom-designed mobile applications, this workforce could be a much-needed resource for other regions in the country, including GB. Strong intersectoral links were developed at the community level in Islamabad to train hundreds of community workers, Lady Health Workers, teachers and students to provide psychological first aid and identify citizens in need of mental healthcare. These experiences can now potentially be replicated in other regions, if they find the requisite political backing.
The ministry is well-placed to disseminate this model to the provinces and special areas like GB and Azad Kashmir, and to support its implementation in collaboration with line ministries. Internationally, there is an encouraging movement to support the cause of mental health through enhanced commitment and funding. As a result, the WHO and many other humanitarian agencies are looking to support low- and middle-income governments that are investing in mental health projects.
The MHPSS model thus promises a way forward to achieve the minimum standards of mental healthcare as outlined in the World Mental Health Report, and turn around mental healthcare for our communities.
Asma Humayun has been 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 7th, 2022