It is said that if one wants to know about a certain society’s moral values, one can do it by witnessing its behaviour towards the mentally ill or other under-privileged communities. In Pakistan’s context, the observation would paint an ugly picture. However, in this piece an attempt has been made to objectively look at healthcare facilities and legislative protection available to the people suffering from mental illnesses in Pakistan.
Pakistan is a South Asian developing country with a population of 140.7 million. Its average population density is 106 persons per square km. Pakistan remains primarily a rural economy with about 30 per cent population living in urban areas and two-fifth (40 per cent) of this urban population living in cities of Karachi, Lahore, and Faisalabad.
Pakistan gained independence from British colonial rule a-half-a-century ago. Traces of the past colonial rule can still be seen in different socio-political spheres. Mental health is no exception. Services available to the mentally disturbed people are limited to three large psychiatric asylums and a handful of general hospital units (2,345 beds). The care delivered at these centres is more penal than therapeutic. There are only 150-200 adequately trained psychiatrists in the country. Most are in private practice and located in major urban areas. Academic frauds are rampant in the government-run public-sector hospitals. Officials are promoted to high ranks because of their political affiliations.
It is astonishing to note that in the last 10 years (1993-2004) only 108 publications have appeared from Pakistan in internationally (peer reviewed) indexed journals. There were only 43 individuals actively involved in research; among these 34 were psychiatrists. This speaks about the dismal state of mental health research in Pakistan. It is also evident that research in high-income countries is not easily transferable or appropriate for use in low and middle-income countries
Community-based epidemiological studies estimate the prevalence rates for depression from 25 per cent to 66 per cent for females and 10 per cent to 44 per cent for males. There are no epidemiologically representative community-based studies on incidence or prevalence of schizophrenia. Its estimates are speculated to be similar to other low income countries in the region (0.8 per cent rural China, 3.8 per cent in Sri Lanka and 5.9 per cent in Kolkata, India). The prevalence of mental retardation is estimated to be two to eight times greater in low income developing countries (like Pakistan) in contrast to industrialised countries. In developing countries the prevalence of severe mental retardation is estimated at 5.2 to 16.2 per 1,000 children (for example, Sri Lanka 5.2 per cent; Pakistan- 15.1 per cent; Bangladesh 16.2 per cent) whereas in western countries it varies from three to five per 1,000 children. According to the Narcotics Control Board, Government of Pakistan, there are 4 million people who are dependent on drugs. There are two million heroin abusers in Pakistan; more than 80 per cent are between 15 to 35 years of age. With an increasing globalisation and social capital erosion people with mental illnesses are at a further risk of deterioration.
Mental health services: The government’s budgetary allocation for the health sector is less than one per cent of the GNP; mental health allocations are negligible. It is estimated that the private sector accounts for some 70 per cent of national expenditure on provision of health services (mostly curative in nature). According to the World Health Report (2004), 100 per cent healthcare payment is out of pocket for Pakistanis. Healthcare has become a lucrative business where firms (hospitals) enter market in order to earn an exorbitant amount of money.
This need-supply gap results in poor quality of services, both in public and private sectors. There is an additional mushrooming of private psychiatric hospitals. Pakistan does not have a government-run welfare system (as in the US) nor does it have a national healthcare system like in the United Kingdom. The rights of the poor, mentally ill or other marginalised individuals are not protected by state. There is no mercy for people with mental illness, poor and marginalised communities. Against this backdrop one reads stories like a mentally ill woman in post-delivery state assaulting her young child.
There are reports on abuse of psychiatric patients. In some centres patients are chained and beaten brutally. In the absence of trained mental healthcare staff there gross negligence is witnessed as far as patients’ management goes. Psychotropic medications are used indiscriminately resulting in serious side-effects and subsequent non-compliance. It is not uncommon to read prescription with cocktail of five psychotropic medications.
Integrated mental health services: The World Health Organisation (WHO) has established a collaboration centre in Rawalipindi. The WHO has provided consultation services and initiatives on many projects to low and middle income countries. These have been implemented with variable success. The management of five common mental illnesses in primary healthcare is one of the options. The illnesses include depressive disorder, psychosis, substance abuse, mental retardation and epilepsy.
The availability of sustainable basic healthcare from Basic Health Units (BHUs) and rural health centres (RHCs) is a major issue. Some years ago the WHO and Pakistan Medical and Research Council (PMRC) did a survey in order to study the reason behind underutilisation of available BHU services. Low numbers and the attendance rate of doctors (63.8 per cent), non-availability of medicines (22 per cent), geographic inaccessibility and low quality of services were cited as some of the major problems. Public sector tertiary care hospitals (TCHs) are a major recipient of the government budgetary allocation, leaving little resources for improvement in the available primary healthcare infrastructure. Employees’ salary compromise 55-to-66 per cent of the budget in these THC leaving little room for technological advancements, equipment and medicines. It is common knowledge that there are many ghost employees. Recruitments are done regardless of merit and thus necessary skill and training is lacking.
The integration of mental healthcare in an ailing primary care system is a difficult issue. This option seems feasible for countries with an established primary healthcare system.
Mental health legislation: Till five years ago, the judiciary was following the modified version of the LunacyAct, 1912. Suicide and attempted suicide were considered a crime according to the Pakistan Penal Code 309. It is a known that the law enforcement agencies extort an exorbitant amount of money from the victims of deliberate self harm (DSH). The new Mental Health Ordinance was promulgated in 2000 which is inadequately implemented. In the absence of a comprehensive legal framework one reads reports on how a relative or a family member was admitted to a psychiatric hospital without proper assessment in order to settle a property dispute. This comes to light only when a non-governmental organisation (NGO) or a patients’ advocacy group highlights the issue in the local media.
In Pakistan, the Pakistan Medical and Dental Council (PMDC) is the sole body for proper licensing and credentialing of physicians. All physicians need to be registered with this central body which has to be renewed after a certain period. The problem lies in the implementation of rules and regulation. One sees a chain of psychiatric hospital claiming to deliver psychiatric care with no qualified psychiatrist on their panel. There is no legal action taken against these people who blatantly exploit patients with mental illness.
There are no specialised forensic facilities or psychiatrists in our country. There are no rehabilitation programmes in place for those proven not-guilty on account of mental illnesses. Psychiatrists and associated professional groups have attempted to de-stigmatise themselves by virtue of “risk assessment”. They merely act as instruments of state machinery. This is done at the cost of further isolating the mentally ill.
Possible solutions: Instead of going for quick-fix solutions, psychiatric services should be developed by training mental health professionals. Research methodology and courses on psychiatric epidemiological should be incorporated into psychiatric training programmes.