Country profiles

Pakistan

Overview

Pakistan is a country comprising of four provinces: Punjab, Sind, Northwest Frontier Province and Baluchistan, in addition to the federally administered tribal areas and federal capital territory of Islamabad, is bordered by China, Afghanistan, Islamic Republic of Iran and India, having a population of 139 million (excluding an estimated 3-4 million Afghan and Bangladeshi immigrants).

Population growth rate is 2.8% and about 41.2% of the population are under 15 years of age (1997) and about 3.8% are above 65 years of age (1997). Total adult literacy rate was estimated at 45% (1997) with a marked sex disparity in favour of males; the adult female literacy rate was estimated at 28%. Based on the most recent statistics, the crude birth rate was estimated at 34 per 1000 population in 1997 and the total life expectancy at birth was estimated at 62.5 years (1996). The infant mortality rate was 86.0 per 1000 live births in 1996 and the maternal mortality rate was 30.0 per 10 000 live births in 1995. The deaths of children under the age of 5 were estimated at 137 per 1000 live births in 1995.

The National ninth five-year development plan (1998-2003) and prospective plan for 2003-13 emphasize the following objectives:

• Equity, efficiency and effectiveness should be the guiding principles for the provision of services.

• The focus should be on improving the quality of health services delivery rather than expansion of the physical infrastructure.

• Emphasis should be on primary health care services, focusing on preventive and promotive aspects by integration of school health, mental health, care of elderly and prevention/treatment of disabilities into primary health care.

• Public education and awareness should be increased regarding the role of lifestyles and behavioural choices in prevention, causation and management of communicable and noncommunicable diseases, including trauma and mental illnesses.

• The private sector and nongovernmental organizations should be involved in human resources development and delivery of health services.

• Drugs on the WHO essential drug list should be manufactured locally in order to reduce costs and to ensure regular availability of these drugs.

• The community should be involved in planning and delivery of health services.

• Drug abuse demand reduction efforts should be integrated with provision of mental health services, through primary health care.

• Family planning programmes and preventive programmes such as the AIDS programme should be integrated into primary health care.

• Community-based medical education should be instituted to make health personnel aware of the community’s needs and demands.

• Decentralization and privatization of health services should be vigorously pursued.

The existing network of health services in the public sector (December, 1996) consist of 865 hospitals, 4523 dispensaries, 4484 basic health units, 513 rural health centres and 262 tuberculosis centres.

There were 89 929 hospital beds and 78 470 registered doctors, 3159 dentists, 28 661 nurses, 4589 lady health visitors and 21 840 midwives.

The ratio of doctors to population works out at 1724 persons/doctor and 5460 persons/nurse.

During the eighth five-year plan period (1993-98), 2015 beds were added at primary health care facilities (basic health units and rural health centres) and 3264 beds were added to secondary and tertiary care facilities (district and general/teaching hospitals). During the same time 9790 doctors, 896 dentists, 5025 nurses, 19 432 traditional birth attendants and 42 000 lady health workers were trained.

MENTAL HEALTH

Pakistan is a signatory to the Alma-Ata Declaration of 1978 which called on the global community to achieve Health for All by the year 2000. Primary health care was the designated approach to achieve this goal, having mental health among its components.

At the time of Pakistan’s creation (1947), there were only three mental hospitals, at Lahore, Hyderabad and Peshawar, and a psychiatric unit at the Military Hospital in Rawalpindi.

It was during the 1960s & 70s that with the development of effective methods of treatment, biological and psychosocial, that psychiatric units were gradually established in all the medical colleges of the country.

Religious magical beliefs regarding the causation and treatment of mental illnesses result in atrocities and brutalities being committed every day with the mentally ill by the faithhealers and quacks, which is further compounded by wide unchecked psychiatric quackery by the medical professionals.

The Institute of psychiatry, WHO collaborating centre for mental health, research and prevention substance abuse at Rawalpindi is coordinating efforts being made to implement the National mental health programme of Pakistan adopted in 1986 and incorporated in the National health policy since 1990.

There are only two centres at Lahore and Karachi for training of Clinical psychologists (C.P) and they are training about 20 CP’s every year.

Psychiatric nursing is being offered as a separate subject at all the nursing institutions in the country and a curriculum for psychiatric nursing has been developed, however currently there are only 52 psychiatric nurses in the country.

There is no provision for training of psychiatric social workers at the university departments, Thirty social welfare officers have received training at the Institute of psychiatry Rawalpindi as part of the man power development initiative.

Epidemiological studies carried out in Pakistan have shown that 10-16% of general population suffers from mild to moderate psychiatric illnesses in addition to the 01% suffering from severe mental illnesses.

Prevalence of severe mental retardation in children between 3 to 9 years of age has been estimated at 16/1000 and according to the recent estimates there are 4 million substance abusers in Pakistan(2000). The most common substance of abuse is heroine (49.7%) and 71.5% of the abusers are below 35 years of age. There are about 232 facilities for drug detoxification all over the country.

In the light of the above given facts it is evident that it would not be possible in foreseeable future to realise the objective of the National programme of mental health i.e. to make mental health care available and accessible for all, if reliance is place on specialized manpower.

AIMS

• Incorporation of mental health components in primary health care.

• Elimination of the stigma attached to mental disorders and substance abuse.

• Universal coverage by mental health and substance abuse services to improve the quality of life.

• Principles of equity and justice be maintained in provision of mental health and substance abuse services.

Since there are gross disparities between need and available services there is need of simultaneous action both at strengthening/expanding existing psychiatric centers and development of mechanisms to integrate mental health including treatment and rehabilitation of drug abusers in primary health care.

The strengthening of existing centers and establishment of new psychiatric centers has become the nucleus of efforts at expanding mental health services.

Integration of mental health including substance abuse treatment and rehabilitation in PHC involves teaching and training of personnel at all tiers of PHC and incorporation of mental health and behavioral sciences in the curricula of health, education social sciences and law enforcement institutions. This approach would provide services at the grass root level and would give wider coverage to the population in a relatively short period of time.

The guiding principles of these strategies would include:

In order to realise the aims of the national mental health programme, a national coordinating group comprising of psychiatrists, psychologists, economists, public health experts and policy makers has been set up. The priority areas for action identified include.

DEVELOPMENT OF MODELS OF MENTAL HEALTH CARE.

It has been a long felt need that models of care relevant to the indigenous needs be developed.

To fulfill this perceived need the WHO collaborating center. Institute of Psychiatry, Rawalpaindi initiated a community based mental health programme at Gujar Khan in 1985.

COMMUNITY-BASES RURAL MENTAL HEALTH CARE PROGRAM.

Existing models of mental health care are for the most part utilised, hospital based, specialist focused and disease oriemted. In developing countries this system has produced care neither consistent with the principles of social equity and nor commensurate with the socio - cultural ethics.

• Community involvement in decision-making and implementation of mental health care delivery system.

• Integration of mental health services in primary health care.

• Application of principles of mental health to improve general health care.

• Intersectional collaboration to enhance the quality of life.

• Identification of priority problems in the community.

• Enabling the primary health care to identify and manage the priority disorders.

• Development of training and teaching models for all levels of PHC personal.

• Development of adequate information system monitoring and evaluation.

• Development of an adequate referral system, to and from the community.

• Provision of essential drugs.

• Development of evaluative projects to determine the impact of integrating mental health cared into general health care.

In order to realise these objectives the programme was started in a phased manner.

This phase involves:

This phase involved:

This phase involved the:

This phase involved:

During this demonstration phase it was realised that schools can be a powerful medium and can play an effective role in stimulating community efforts for mental health care provision. This realisation led to the development of school Mental Health Programme in Gujar Khan.

This literacy rates of Pakistan is roughly around 31% and in rural areas this is even lower: the female literacy rate may be as low as 7% (Annual report on education, 1995). Therefore, the school going children and the teachers constitutes the bulk of the literate. They read and write letters for their elders. Fill official forms and read newspapers for them. Thus they become eminent in the community and induce some parents to send their children to school. They are rightly called as the "eyes and areas of community" (Mubbashar, 1986).

The objectives of school mental health programme are:

These objectives are being met through a series of four phases: familiarization, training, reinforcement and evaluation.

Before the start of the programme, the district school authorities were contacted; the aims and objectives of the programme were explained and their cooperation was sought. This phase involved collection of background information on the existing educational facilities. In addition, teams visited various schools of the field area to assess current mental health knowledge among the heads of schools, teachers and students and their willingness to support and own the programme. During this phase, medical camps were organized at various schools once a week for providing them counseling on various medical and psychiatric illnesses. The aim of this expertise was to gain their confidence and establish rapprot with t he school authorities for the acceptance and success of the programme.

During this phase, the knowledge of teachers about mental health and illnesses was also assessed. It was noted that the majority of teachers had very limited knowledge of mental health and many teachers shared the rural community’s views about the causation of mental illness being due to the influence of evil spirits, etc. This socio-economic stress and unhappy environments were also considered as potent causes of mental ill health (Mubbashar et al 1986),

The training was mainly directed towards changing the attitudes of the teachers towards mental health. In addition, it was aimed to provide knowledge of common mental illness and basic aim of psychological counseling when needed. The training was done in a decentralised manner.

During this phase the following activities were carried out:-

The slogans are:

Numerous posters carrying these slogans were designated by the school children themselves which now are displayed in most of the class and staff rooms. The teachers from their own resources organise the production of the rubber stamps carrying these catchy phrases.

During this phase the impact of the programme was assessed in the following areas:-

Faith healers and religious leaders are the first port of call for majority of the mentally ill patient s. thus the potential benefits of involving the faith healers instead of antagonizing them in the provision of mental health services are manifold, the for most being the perception by the community that services are in line with their health belief system. After the initial reservations has been overcome a relationship beneficial to the mentally ill in the community was forged.

One particular research project in this regards is worth mentioning which shows that about 25% of the patients presenting to faith healers in Gujar Khan sub-district of Rawalpindi were given the "Medical diagnoses" and referred to nearest health facility, a significant departure from past practices.

This model was initially developed in two sub-districts of Rawalpindi, but presently this model is being replicated in all provinces of the Pakistan.

Over the last one year some far-reaching developments have taken place.The most important of which is inclusion of mental health trainings in the programme of District Health Development Centres. These centres have been set up to build the capacity of primary care personnel to handle emerging the common health problems, by organizing on job training for them. Mental health has been included in the regular programmes of trainings being run by these centres in Punjab and over the next 02 years it would be generalized to the other provinces.

Another major development has been the acceptance in principle to include indicators for mental illnesses as part of the National Health Management Information System. This would be a Crucial development for integrating mental health in PHC.

NGO's are taking on an increasingly important role in developmental activities. National Rural Support Programme (NRSP) is the organization active in the field of income generation,education, agriculture, forestry,tourism and health having access to about 20,000 village level organizations.

NRSP and its sister organizations have agreed to include mental health amongst, all its activities and about 20,000. Community activists would be trained each year through this initiative highlighting the role of mental health in national development activities.

Another major breakthrough has been the inclusion of mental health component in the teacher training programmes at national level. Training of master trainers from all provinces (batches of 40 for four months each) would start from January 2001.

Text book boards of all provinces are being approached for inclusion of mental health issues in the school curricula being prepared by them.

Declaration by the WHO of 2001 as Mental health year with provide the impetus to all these developments.

Special issue of the journal of college of physicians and surgeons Pakistan the regulatory body for post graduate education in Pakistan, is being brought out in April 2001 to commensurate it. In addition special issues of leading newspapers, symposia and workshops have been planned across the country to promote ‘mental health literacy’.

2.2

In the light of extreme paucity of specialized manpower in the country, a multipronged strategy targeting all tiers of health professionals already working within the health delivery system along with undergraduate medical and nursing students and allied professionals was conceived and put in practice.

UNDERGRADUATE MENDICAL EDUCATION.

At the undergraduate level/ Behavioral sciences’ have been incorporated in the curricula of all the medical schools in Pakistan. An indigenous behavioral sciences teaching modules has been developed for medical students.A demonstration project of community oriented Medical education with a significant, stress on behavioral sciences has been launched in all the four provinces of the country.

2.2.2

POSTGRADUATE MEDCICAL EDUCATION.

At the post graduate level. Fellowships, MD and diploma courses are available. The college of physicians & surgeons Pakistanis is the regulatory body for post graduate education in the country and all the departments of psychiatry at medical colleges are evaluated on a regular basis for certification of training.

2.2.3

TRAINING OF PRIMARY CARE PHYSICIANS.

All the departments of psychiatry in Pakistan re actively involved in training GP’s and primary care physicians utilising the manual developed at the institute of psychiatry, Rawalpindi. More than 2000 PCP’s have so far been trained in mental health at the following centers:

2.2.4

TRAINING NURSES

A curriculum adapted to the local needs have been developed for undergraduate as well as post graduate psychiatric nurses.

At the undergraduate level psychiatry is taught during 2^nd, 3^rd & 4^th years of training along with practical training.

Two years postgraduate diploma for psychiatric nursing has been initiated in nurses training colleges in the country and so far 92 psychiatric nurses have qualified.

In addition to theses development 287 nurses have been trained at the Institute of Psychiatry, Rawalpindi in community psychiatric nursing.

2.2.5

ORIENTATION OF HEALTH ADMISTRATORS IN MENTAL HEALTH.

In order to realise the objective of integrating mental health in primary health care, it is essential that health administrators be sensitized to the importance of mental health.

Majority of the policy and field level administrators have been provided with orientation in the field of mental health, including those from the armed forces, at the Institute of Psychiatry, Rawalpindi . This particular activity has resulted in setting up of mental health training programmes as part of the ongoing in service training.

2.2.6

ORIENTATION OF EDUCATION ADMINSTRATORS:

Given the importance of education sector, particularly in prevention of mental illnesses and promotion of mental health, orientation of education administrators in an imperative. So far more than 150 education administrators from all provinces have been provided orientation training. Currently mental health has been included in the core curriculum of science teachers and efforts are under way to integrate component of mental health in school curricula.

2.2.7

TRAINING OF LHV, LHW’s AND MPHW’S:

LHV’s, MPHW’s & LHW’s training manuals have been prepared at the Institute of psychiatry, Rawalpindi and so far more than 40,000 LHVs, LHWs and MPHWs have received training all over the country, in a decentralized manner. Training is being carried out under the District health development centers initiative.

2.2.8

In addition of the development of teaching and training material for PCP’s ,LHV’s,LHW's and paramedics, the Institute of psychiatry at Rawalpindi has been active in the development of information systems for use at primary and tertiary care facilities.Inclusion of mental health indicators have been agreed upon in principle in Health Management Information system at national level.

2.2.9

The Institute of psychiatry has so far trained more than 65 junior psychiatrists in community mental health to act as resource persons in development of community mental health program in their areas, with WHO support,to provide the training referral and evaluation support to integration of mental health in PHC.

2.2.10

In addition to psychiatrists from Pakistan , mental health professionals from-

Have been trained at the Institute of psychiatry, Rawalpindi in community mental health, to act resource person in their respective countries.

Pakistan has been involved in training of physicians in the field of mental health and setting up of mental health services in the Northern parts of Afghanistan under the auspices of WHO.

In collaboration with Tribhuvan University, Institute of medicine Nepal the Pakistan has set up the MD training programme in psychiatry. Similar programme is being set up in Bangladesh.

3.0

RESEARCH AND PUBLICATIONS.

Lack of indigenous research has been a major hindrance in rational planning and allocation of resources, however over the last few years a number of research papers have been published. Major areas of research activity include:

. community based surveys of psychiatric morbidity.

66% of women and 25% of men were suffering from depressive illness and anxiety disorders.

Negative correlation’s between BSI and SRQ scores and socio-economic factors.

Socio-economic status and psychiatric disorders are inversely related to each other.

Greater risk of psychiatric disorders among men and women of younger age group and lower levels of education.

THE PREVALENCE, RECOGNITIN AND MANAGEMENT OF PSYCHIATRIC DISRODERS AMONG PRIMARYCARE ATTENDERS.

PSYCHIATRIC MORBIDITY AMONG FAITH HEALERS ATTENDEES PREVALENCE RECOGNITION AND TREATMENT OF PSYCHIATRIC DISORDERS AMONG NATIVE HEALERS ATTENDEES.

The study found an overall prevalence of psychiatric morbidity of more than 60% amongst the native healers attendees.

This study assessing the mental health of prisoners held at Rawalpindi District Jail focused on convicted male prisoners serving sentences of more than 10 years, mainly for homicide.

Almost all the long term prisoners irrespective of how long they had been I prison indicated that the problems which weighed most heavy were the perception that life was passing by and that they were separated from their near and dear ones. They had major concerns that their children and family would be affected by their imprisonment and they felt bored and sad. These have a common theme of loss experienced by the prisoners as a consequence of their imprisonment.

4.0

PREVENTION AND REHABILITION:

It has been well documented that prevention of mental illnesses is not only desirable but feasible as well. In this regard public education has been accepted as the pivot for all preventive efforts.

Institute of psychiatry, Rawalpindi along with academic departments of psychiatry and other sectors had developed public education material focusing on the contribution of life styles and behavior towards primary, secondary and territory prevention of mental illnesses. School mental health programs and clear vision project are efforts geared towards this end.

One particular study (PRIDE Project) which has been carried out in Iodine deficiency areas of Pakistan in collaboration with the center for international child health, Institute of child health, U.K. has demonstrated the beneficial effects of Iodine supplementation on the cognitive performance of school going children.

Multisectoral efforts in the field of child abuse prevention and support for victims of torture & abuse have started showing results with desirable change in the attitudes of communities towards the victims.

Rehabilitation programmes are being developed involving broad-based partnership between public & private sector institutions for drug dependants, mentally handicapped and chronic psychotic patients.

In this regard the FOUNTAIN HOUSE , LAHORE has developed a programme of chronic schizophrenics involving pre-vocational training, transitional employment programme and Agro & Silvo therapy programmes.

Formation of mental health consumer groups is a new development which has gained impetus over the last 02-03 years and are playing a leading role in education about mental illnesses.

5.0 INNOVATIONS AND NEW DEVELOPLMENTS:

5.1 LEGISLATION

The government of Pakistan has repealed the Mental health act of 1912-26. the new mental health law embodying the modern concept of mental illnesses, treatment rehabilitation, civil and human rights has been enactedon 20^th february 2001 as the law on the national mental health day.

5.2 INCORPORATION OF MENTAL HEALTH IN PRIMARY HEALTH CARE.

The 9^th five year plan of the Government of Pakistan emphasizes the above as one of its objectives and development of training modules for community workers has already been completed.

In the next phase training of master trainers and field trainers would start and this whole effort will be linked with the ongoing training of primary health care personnel.

5.3.

Development of models of care and action at the policy formulation levels has been supported by evaluation of these activities to bring the necessary modifications.

In this regards the following research and evaluative activities have been carried out:

EVALUATION OF SCHOOL MENTAL HEALTH PROGRAMMES:(studies available on request).

Results;

A case control prospective study has shown that the impact of school mental health programme is not limited to the children themselves ,rather it tends to bring about a change in the mental health related kowledge and attitudes of their parents ,neighbours and non- school going friends . study concluded that school children can be effective agents of change in a community regarding mental health related kowledge and attitudes

EVALUATION OF THE IMPACT OF COUMMUNITY MENTAL HEALTH PROGRAMME ON UTILIZATION OF PRIMARY HEALTH CARE SERVICES -DEVELOPMENT OF INDICATORS FOR HEALTH CARE SYSTEM.

After the introduction of community based rural mental health programme in the Index area there was significant increases in detection of psychiatric cases, the detection rates are 7-12% in female in the Index area, the comparable figure in control area are 0.3% -1.2% in female.

Prescription of psychotropic drugs in Index area 74.6-91.2% in male and 71.1-88.1% in female, while the comparable figures in control area are 40% - 64.3% and 25-125% in females.

The number of enrollments for antenatal care and assisted deliveries was remarkably higher in Index are than control area.

The rates of antenatal care are 56% to 69% in Index area, while the rates are 55% to 66% in control area. In the Index area assistance was provided to 30-50% of deliveries while only 27-43% of deliveries were assessed in control area.

The mental mortality was reduced 0.56%-0.9%/100 pregnancies in control area but no significant differences were noted regarding infant mortality rate in Index area than control area.

6.0

CONCLUSIONS:

Integration of MENTAL HEALTH into PRIMARY HEALTH care not only is possible but can also ‘SPEARHEAD’ PHC and result in positive effects on utilization of general health service. These results can enhance political commitment and can change policies.

School Mental Health programme is an effective strategy for DESTIGMATIZING mental illness

School children and teachers in addition to being the "EYES AND EARS" of the community can also act as "AGENTS OF CHANGE" for prevalent attitudes and superstitions about Mental Health problem.

Native faith healers can be an important resource for providing effective and culturally appropriate treatment for a large number of mentally ill at their doorstep.

Glasses are the CHEAPEST MENTAL HEALTH AID money can buy and can prevent children from DROPPING OUT of the schools into CHILD LABOUR.

Mental/Cognitive deficits in children can be PREVENTED by giving IODINE to women in reproductive age.

It can be safely concluded that in Pakistan mental health is making progress towards its goal of integration of primary health care. It is this strategy which is going to pave the way to making mental health play its legitimate role not only in improving the quality of life of mentally ill patients but also in national development.

7.0.

Intersectional collaboration particularly with education and NGO's sectors should be expanded to promote mental health literacy at gross root level.

Linkages between university departments of psychiatry and public health delivery systems be strengthened enhancing each other, capacities for service, research and evaluation.

Manpower intellectual and material resources should be pooled to avoid replication and wastage, while overcoming the paucity of resources at the same time.

Leadership development for maximization of potentials.