ASIA & SUB-CONTINENT
Only 0.3% of the health budget is spent on mental health. 87% of this amount goes towards mental hospitals. The taxing struggle to access care could be increasing mental illness, as well. Insufficient financial allocation and a poor pool of human resources are the major restraints on better care for a country that has relatively affordable drugs and decent awareness and monitoring systems.
Myanmar has a dangerously low 0.477 human resources per 100,000 general population, half of which are nurses. Myanmar has 0.16 psychiatrists per 100,000. The country has 89 total psychiatrists; the World Health Organization would recommend a minimum 356 psychiatrists for Myanmar's population. This does not seem likely to improve soon, as only 4 psychiatrists graduated from Myanmar universities in 2006, and as many as 20% of psychiatrists emigrate away within five years of receiving their degree.48 The country also only has four total psychologists and one occupational therapist.49
Access to drugs is strong, with at least one of each kind of psychotropic drug available in inpatient facilities, outpatient facilities, and mental hospitals. 31% of the population has free access to mental health care, when free psychotropic drugs are available from the hospital. For those paying out of pocket, antipsychotic medications cost 6% of daily minimum wage, and antidepressants cost 9% of daily minimum wage.
There is extremely low outpatient care for adolescents, who make up less than one percent of all outpatient users. There are also no mental health professionals working at any primary or secondary schools in the country. The care at the one day facility specifically for youth is far more tailored to mental retardation and disability than mental illness. Only 30% of these patients are female, suggesting a gender inequality of youth mental health care access.50 Adult females seem to also struggle with equal access; only 20% of patients at the country's two mental hospitals are female.
70% of the population lives in rural areas. There are 1500 rural health centers, but very little psychiatric care in rural regions. The density of psychiatric beds per population is over ten times greater in cities than rural regions, and the density of psychiatrists is over four times greater in cities than rural regions.51
There is a monitor and research board which annually collects and publishes data collected from across the country. This information is community based, increasing the representation of the data, and is collected using a data dictionary to ensure standardized terminology and clear definitions of illnesses.52
There have been public education campaigns delivered collectively by traditional, conventional, and modern medicine providers. It is unclear if these campaigns are consistent, and if they ever target the general public or only focus on targeting professional groups and health care providers.
Traditional medicine is still actively practiced in Myanmar. There is a University of Traditional Medicine, and the country's comprehensive health plan can be applied to traditional medicine.53 85% of the country uses traditional medicines, either as a supplement to Western medicine or as an alternative. This is in part because traditional medicine is ten to twenty times cheaper than Western medicine. Traditional medicine is also readily accessible, with over 10,000 traditional medicine practitioners across the country.54
A human rights body exists, and has the capacity to oversee general facility inspections, involuntary admissions reviews, complaints, and discharge procedures.
48 World Health Organization, “Mental Health System in Myanmar,” WHO-AIMS REPORT (2006): 18.
49 WHO iv.
50 WHO 5.
51 WHO 8.
52 WHO v.
53 WHO 20.
54 IRIN: Humanitarian News and Analysis, “Myanmar: New Lease of Life for Traditional Medicine,” Oct 12 2009.
Pakistan's human resources and facilities outpace similar low and middle income countries, but a lack of funding and failure to guarantee equity for those with mental illnesses has prevented Pakistan's mental health system from joining the ranks of higher income countries.
Pakistan's mental health policy was revised in 2003, and included development of community mental health services, downsizing mental hospitals, great advocacy and equity, human rights protection, and a new approach to financing mental health needs. The country also enacted an emergency preparedness plan in 2006. Despite these broad goals, only 0.4% of the government's health care expenditures were allotted to mental health.55 This is surprisingly low, especially considering the high contact rates and human resources available. This low allotment is likely affected by the poor general health structure, and the pressing need for more public hospitals and services outside of major cities.56
Only 5% of the population has free access to essential mental health drugs. Drugs are relatively affordable, with antipsychotics costing 3% of the daily minimum wage and antidepressants costing 7%.
Pakistan's facilities effectively make and maintain contact. The 3729 outpatient mental health facilities in the country treat 343 users per 100,000 general population, and the average number of contacts per user is 9.31. A strong follow-up care system in the community is utilized by 46% of patients. The outpatient facilities are also organizationally integrated with mental hospitals, allowing patients to easily access the care most appropriate for them.57
Pakistan's human resources have been well-trained in mental health, with an exceptional 27% of training for medical doctors devoted to mental health.58 The burden for mental health care in Pakistan is placed strongly on doctors; only 3% of nurses' training is devoted to mental health. This differs from many countries with lower GDP per capita, in which doctors' work is far more focused on physical care and endemic diseases, and nurses have a higher percentage of their training devoted to mental health.
There are 87 human resources working in mental health per 100,000 general population. This is very strong. Of note is that there are 75 times more non-psychiatrist doctors than psychiatrists practicing in the field of mental health (0.2 psychiatrists per 100,000 vs. 15.37 other doctors). This is explained in part my college graduation rates: 2.1 medical doctors graduated per 100,000 population in 2008, compared to only 0.002 psychiatrists. Those who do go to school for psychiatry are often offered higher salaries from Western states and choose to emigrate.59 The medical doctors who practice psychiatry have been well-trained due to the Pakistani schools' emphasis on mental health, but it would be preferable for a significantly higher percentage of the practicing doctors to be psychiatrists. Psychiatrists are very well distributed across sectors, with 45% working in government facilities, 51% in NGOs or for-profits, and 4% in both.
68% of the population is rural. Pakistan's psychiatrists, like many comparable countries, are concentrated in urban areas. The density of psychiatrists in the largest city is 2.29 times greater than the countrywide density.
Public education campaigns have been led by the Ministry of Health, NGOs, professional services, and private trusts, and are overseen by a coordinating body. They have most often targeted vulnerable populations, including children, women, trauma survivors, and ethnic groups. There is legislation that similarly supports that with mental illness, including provisions to hire disabled people, provisions to ensure fair access to housing, protection from job dismissal on account of mental illness. This legislation, however, is rarely enforced.60 Inequity of access for linguistic, ethnic, and religious minorities is a moderate issue.61 There are also many anecdotal stories of stigma and the shame felt by families of those with mental illness, such as this schizophrenic painter. It is still common to believe that mental illness is the result of "a curse, a spell, or a test from God."62 Thus, those afflicted often turn to religious healers rather than mental health professionals for support.
A monitoring system is in place, and all mental health facilities submit information to it. This allows for a range of research on topics such as mental illnesses present in the country and the success rate of different forms of personal and medical intervention.63 The quality of research coming out of Pakistan has been criticized by academics, saying that the papers are produced for promotions and do not achieve a high standard.64
55 World Health Organization, “Mental Health System in Pakistan,” WHO-AIMS REPORT (2009): 8.
56 WHO 26.
57 WHO 5.
58 WHO 6.
59 Gadit, Amin, “Mental Health in Pakistan: Where Do We Stand?” Journal of Pakistan Medical Association, May 2006.
60 WHO 23.
61 WHO 27.
62 Gilani, Ahmed, “Psychiatric Laws in Pakistan: From Lunacy to Mental Health,” PLoS Med, Sep 20 2005. http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed....
63 WHO 24.
64 Gadit 1.