MIDDLE EAST

Afghanistan

Afghanistan has an abysmally poor mental health system, with entirely inadequate funding, human resources, and urban-rural balance to care, among other problems. The only upside is the policy proposals that would increase training and education; these projects, though, are strongly reliant on outside donorship to become a reality.

Access

In a 2004 national survey, 68% of Afghanis had some form of depression, 72% had anxiety, and 42% had PTSD.82 The level of access does not meet the level of need. Less than one percent of the general population has free access to psychotropic medicines. For those paying out of pocket, antipsychotics cost 12% of the daily minimum wage, with antidepressants costing 16% of the daily minimum wage. There is no coverage of mental disorders under social insurance.83

Health makes up 5.2% of the national GDP of Afghanistan, allowing a budget of $290 million. Of 2004's total health budget, only $0.1 million was directed for mental health.84 The limited mental health resources allocated each year often go to the mental hospital, creating a situation of dire underfunding of inpatient and outpatient facilities.85 NGO funding now provides basic services to 85% of Afghanis, but lack of quality data on mental health problems and a scarcity of human resources has inhibited development of cost-effective mental health intervention.86

There are only two psychiatrists practicing in Afghanistan, and neither work in mental health facilities.87 In total, there are a mere 0.5 workers per 100,000 population. This breaks down to 0.008 psychiatrists, 0.24 non-psychiatric doctors, 0.14 nurses, and 0.16 mental health workers. There are zero psychiatrists, psychologists, social workers or occupational therapists working in outpatient facilities, community-inpatient facilities, or in the mental hospital.88 The WHO's minimum recommendation is 0.4 psychiatrists per 100,000 – that means Afghanistan is recommended to minimally have 140 psychiatrists in the mental health field for their population of 35 million, but as of the most recent high quality reports in 2005, they had none. There also were zero psychiatrists or psychologists graduating from educational institutions in the year of that report, showing that the void is not being filled.

The only mental hospital is in the capital city, with sixty beds. However, 78% of the population is rural. As of 2006 there was no development of community mental health facilities in rural regions.89

Policy

The Mental Health Strategy was set in place in 2005, with the intention to integrate mental health care, increase promotion of mental health care, and reduce stigma by the year 2020.90 The first stage would be to establish a mental health unit within the general health care department. In 2009 Afghanistan expanded to its Mental Health Strategy to include mental health treatment and counseling training manuals for doctors; basic counseling manuals for nurses, midwives, health supervisors, and community health workers in English and Dari; and one year curriculums developed for training of psychosocial counselors.91 This was one bright sign in Afghanistan's mental health picture, with some success coming in the pilot programs. The programs succeeded in increasing capabilities to identify and report mental health disorders.92 The main funder of the program is the EU.

Culture

The lack of mental health awareness and the institutional failure to support those with illnesses has created stigma and human rights violations that have gone unaddressed. There is no financial or legislative support for those with psychiatric problems in Afghanistan. WorldBank has stressed the importance of building education and awareness in the country, considering it the affordable and reasonable prerequisite to changing policy (WorldBank 2). However, there is no coordinating body of mental health awareness campaigns, nor any interagency collaboration.93 There has been no successful promotion of equal access to mental health services.94

Afghanistan has a human rights body, but it only reviewed one patient protection claim in the closely examined year of 2004.95 There is neither supervision nor monitoring systems in place across the mental health regime, and no training or working sessions on human rights for staff of mental health institutions.96 This lack of awareness on the ground is particularly dangerous because 40% of all mental health admissions are involuntary, which could promote a culture of conflict between staff and patients. Hospitals do not report involuntary admissions, restraining of patients or duration of stay.97

The greatest mental health stigma reported was the stigma towards epilepsy, which is classified in Afghanistan as a mental health disorder. The stigma is so harsh that these individuals are considered in need of both therapeutic treatment and psychosocial counseling to rebuild self-esteem.98

As a result of little awareness and cultural support, people most often turn to Islam to cope. The most common coping methods in a survey of the general population were reading the Quran (37%), praying (28%), and talking to family (9%). In Eastern Afghanistan, 98% said that Allah is their main emotional support when they are sad, worried, or tense.99

82 Sayed, Ghulam Dastagir. "Mental Health in Afghanistan Burden, Challenges and the Way Forward." The World Bank: Health, Nutrition and Population 1 (2011): 6. 
83 World Health Organization, “Mental Health System in Afghanistan,” WHO-AIMS Report  (2006): 4.
84 WHO 1.
85 WHO 3.
86 Sayed 2.
87 WHO 2.
88 WHO 13. 
89 WHO 2.
90 Sayed annex II.
91 Sayed 11.
92 Sayed 12.
93 WHO 2.
94 WHO 3.
95 WHO 1.
96 WHO 5.
97 WHO 8.
98 Sayed 7.
99 Sayed14.

Iran

The integration of mental health policy in Iran has demonstrated a strong political will and dedication to creating proper infrastructure to meet mental health needs, but greater funding would be beneficial to help reach the rural population and build the human rights protection regime.100 3% of the country's health care expenditures go to mental health. 

The government provides no national data on mental health disorders. Independent findings show that 25.9% of women and 14.9% of men are likely cases of mental illness. The prevalence rate climbs to 31.5% for those over age 65, and 42.4% for divorced or widowed individuals. The social group with the highest risk of mental illness was the unemployed, who were 1.8 times more likely to be at risk of mental disorder than the employed population.101

Access

53% of the population has free access to essential psychotropic medicines. For those paying out of pocket, antipsychotics cost 4% of minimum daily wage, and antidepressants cost 2% of minimum; this is a relatively low cost compared to comparable Middle Eastern countries. All mental health outpatient facilities had at least one psychotropic medicine of each class consistently available on-site or at a local pharmacy.102

66% of Iran's population is urban, 34% rural. The equity in care between urban and rural has improved greatly over the last twenty years, but it is still not fully balanced. There are still two times more psychiatric beds per capita in cities compared to rural areas.103 This may be in part due to the concerted effort to provide free services to the urban poor of Iran. This program is impressive but not incredibly effective, as the services are utilized by the urban poor at a low rate.104

There are 61.2 mental health workers per 100,000 Iranians, far exceeding Iran's geographical neighbors. This includes 1.2 psychiatrists, 2 psychologists, 10.7 non-psychiatric doctors, and 7.8 nurses per 100,000 Iranians. The outpatient facilities in the country are active, treating nearly 1 in 100 of general population. The day treatment facilities see 2.78 people per 100,000.105 Community-based facilities have 2 beds per 100,000 population, community residential facilities have 5 beds per 100,000, and mental hospitals have 8 beds per 100,000.

Policy

Iran's success can be attributed in part to its reasonably well-established policy. It has been in place since 1986, and focuses on advocacy, promotion, prevention, treatment, and rehabilitation.106 Under this policy, Iran has developed community services, built psychiatric wards in general hospitals, improved the human rights protection for its users, increased equity of access, and built a monitoring system.107 It also includes a disaster preparedness plan for mental health, based on a late 1990s need assessment on the mental health systems required following an earthquake. The policy has led to improved skills of workers and rural services, and has successfully integrated mental health into the primary health care system.108

Culture

Education and awareness has been a priority in Iran. There is a coordinating body that exists to oversee public awareness campaigns. In recent years there have been promotion efforts from government agencies, NGOs, professional groups, private trusts, and international agencies.109 The country has celebrated Mental Health Week at the end of October each year since 1985, which serves as an annual time for a focused push for awareness.

There have not been many reports of stigma from studies by international agencies, and stigma went unmentioned in the WHO-AIMS 2004 report. However, interviews with mental health patients in 2011 shows that they feel they are discriminated against and cannot fit in to society. More than half of those interviewed tended to agree with statements such as "I am disappointed in myself for having a mental illness," and "negative stereotypes about mental illness keep me isolated from the normal world."110 In a subjective self-assessment, 40% of Iranians surveyed with mental illness felt moderate to severe stigma, while another 40% felt mild stigma. While Iran has succeeded in public awareness campaigns, this research suggests that the average Iranian with mental illness feels unwelcomed in Iranian society.

Human rights protection is an area of relative weakness for the Iranian mental health system. There are no laws to prevent against discrimination, including dismissal or lower wages, for individuals with mental illnesses. Legislation exists to obligate employers to hire a certain number of mentally retarded individuals, but it is not closely enforced. As of 2005, there is no review or inspection process to ensure human rights in mental health facilities.111 The mental health regime as a whole lacks equity for non-Persian speakers, who struggle to find care in the system due to the overwhelming dominance of Persian language in Iranian culture.112 This is a place for improvement in an otherwise strong mental health care system.

100 World Health Organization, "Mental Health System in the Islamic Republic of Iran," WHO-AIMS Report (2006): 9. 
101 Noorbala, A.A., "Mental health survey of the adult population in Iran," British Journal of Psychiatry 184 (2004): 71.
102 WHO 12.
103 WHO 13. 
104 WHO 14.
105 WHO 12.
106 WHO 8.
107 WHO 12.
108 WHO 8.
109 WHO 24.
110 Ghanean, Helia, "Internalized Stigma of Mental Illness in Tehran, Iran," Stigma Research and Action 1.1 (2011): 13.
111 WHO 27. 
112 WHO 14.

Iraq

Iraq has worked to raise the bar of its mental health care, but has come up short in its availability of drugs and human resources, its rural access, and its equality of access.

Access

Health makes up 3.2% of GDP in Iraq. All National Health Service is free, theoretically allowing for complete access to medications. In reality, though, there is a limited supply of drugs. For example, for a two month period in 2004 there was no access to antiepileptics. Out of pocket, antipsychotic drugs cost 10% of daily minimum wage, and antidepressants cost 8% of one day of minimum wage.113 It is unclear whether the aforementioned shortage is only for the drugs supplied by the National Health Service, and whether it is still possible during these times of limited supply to buy drugs at the out of pocket price.

There are a total of 1.6 mental health professionals per 100,000 population. This includes 0.33 psychiatrists (falling below the WHO recommendation of 0.4), 0.02 non-psychiatrist doctors, 0.53 nurses, and 0.05 psychologists.114 The country's facilities include 25 outpatient mental facilities, 4 for children only.

The urban-rural care divide is notable in Iraq. There are four times more beds in Baghdad than other parts of the country, and limited rural mental health access.115 97% of psychiatric beds are in or near Baghdad. In 2008, the country began a new project to build three community-based social and mental support facilities in northern Iraq, primarily to meet the needs of women and girls affected by the war.116 This was a strong improvement for access in northern Iraq.

Policy and Education

There have been recent small steps made to improve policy and education. In 2005, new legislation focused on access to care, rights of family and caregivers, guardianship issues, overseeing treatment practices, and mechanisms to implement new laws.117 It lacked any provision, though, to combat employment or housing discrimination. Iraq has had a history of moderate inequity regarding access to care for linguistic, ethnic, and religious minorities.118

There is a mental health council that oversees education and awareness campaigns. It has recently chosen to target awareness campaigns towards teachers and religious leaders. The council has also made campaigns targeting professional groups, health care providers, and social service staff in the past.119

113 World Health Organzation, “Mental health System in Iraq,” WHO-AIMS Report (2006): 8.
114 WHO 15.
115 WHO 5. 
116 World Health Organization, "Mental health system strengthened in Iraq, Jan 28 2009. 
117 WHO 8.    
118 WHO 12.
119 WHO 18.

West Bank and Gaza

The Occupied Palestinian Territories (oPt) spends $2.5 million annually on mental health, 73% on mental hospitals. The health care system across the territories is still rather fluid, and was categorized by the WHO as being in "the evolution/development stage," and that the prevalence of infectious disease deaths are being phased out.120 One of the greatest concerns is addressing trauma in the region, as seen in this Doctors Without Borders video series. The oPt have better hopes for improvement than comparable countries, though, because the investment of outside countries and NGOs are helping to support the implementation of a well-developed policy to be implemented in the near future.121

Access

The population has free access to essential psychotropic drugs. For anyone needing to pay out of pocket, antipsychotic medication would cost 23% of the daily minimum wage, and antidepressants would cost 15%.  Both mental hospitals also have consistent access to at least one form of each psychotropic drug. The hospitals have been unable to maximize their cooperation, as the hospitals in the West Bank and Gaza are under separate structures within the Ministry of Health.122

Sixty percent of the population lives in villages or refugee camps.123 However, 88% of psychiatry beds are in or near the largest city. Rural populations have considerable trouble accessing mental health care for serious needs. The active conflict also makes access difficult, as seen in the violence at the Bethlehem Mental Hospital in 2004.

Human Resources

There are a relatively strong number of human resources in the mental health field, with a total of 7.31 human resources per 100,000 population. This includes 0.87 psychiatrists, 0.98 psychologists, and 3.43 nurses per 100,000. 57% of all workers are in the public sector, working for the Ministry of Health, with the other 43% working in the nongovernmental sector. Schools are still consistently graduating psychiatrists and nurses, and none of the psychiatrists have emigrated to other countries following graduation.124

Only 1% of medical doctors' training is devoted to mental health, but 9% of nursing training is devoted to it. There is a similar imbalance of retraining, with no primary care doctors receiving mental health refresher courses, but 27% of unspecialized mental health workers receiving refresher training. 

Culture

There are human rights organizations at work in oPt, but none of them have the authority to oversee or impose sanctions on mental health professionals.  This is worrisome, considering that the most recent figures from 2005 show that 40% of all mental hospital admissions are involuntary. There are plans for future legislation to put a human rights monitoring body in place.125. There is a monitoring system in place that collects basic data from all mental health facilities including beds, admissions, lengths of stay, and patient diagnoses.126

Mental health awareness has been promoted by an array of organizations including UNICEF, WHO, and the French and Italian Cooperations. They have chosen to target teachers, health care providers, and the general public, but have not made any attempt to reach the vulnerable populations of women, adolescents, and trauma survivors.

120 World Health Organization, “Mental Health System in West Bank and Gaza,” WHO-AIMS Report (2006): 9.
121 WHO 25.
122 WHO 24.
123 WHO 8.
124 WHO 21.
125 WHO 12.
126 WHO 24.