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Mental Health Care: a Blind Spot in the Bangladeshi Health System

Dr. Moyukh Chowdhury,

SNIH Advisory Board Coordinator,

Umea University

Dr. Shuchesmita Das,

Medical officer and Clinic Manager,

Urban Primary Health Care Services Delivery Project, Bangladesh

 

 

Prologue:

Mental well-being is a fundamental component of WHO’s definition of “health” and one of the major public health concerns of this era, in which mental disorders contribute about 13% to the total global burden of diseases (1). Apparently,  it is a more challenging issue among low-middle income countries, and Bangladesh is no different. According to the National Mental Health Survey from 2003-2005, around 16% of the adult population in the country has been suffering from mental disorders, which has increased from approximately 7 to 31% among adults and from 13 to 23% among children within the past decade (2,3). Due to strong social stigma attached to mental disorders in the local society, the prevalence in both groups is likely to be underestimated.  Despite the numerous significant achievements in improving health indicators, structural enhancement of health systems, and hence the global appreciation throughout last couple of eras, unfortunately not much significant measures have been observed in the national health structure of Bangladesh to combat the emerging challenge of mental health.

 

Bangladesh and the health web:

Bangladesh is the most densely populated country of the world, with a geographical area of approximately 147,570 km² (4). 74% of the population lives in the rural area with an average life expectancy of 62-63 years among males and females respectively (2). The health system of Bangladesh is comprised of four main components that define the structural and functional system: Government sector, Private sector, Non-Governmental Organizations (NGO) and International organizations.

The Government sector plays the key role, and is responsible by constitution for policy and regulation of comprehensive health services. The health system of Bangladesh is mainly coordinated by the Ministry of Health and Family Welfare (MOHFW) and executed through different regulatory bodies. The MOHFW implements its service, rules and regulations through two executing authorities: the Directorate General of Health Services (DGHS), and the Directorate General of Family Planning (DGFP). The DGHS and DGFP manages a dual system of general health and family planning services through medical colleges with specialized hospitals, district hospitals, Upazila Health Complexes (Upazila is equivalent to sub district or borough), Union Health and Family Welfare Centers at union level of villages, and community clinics at ward. In addition to this, The Ministry of Local Government Rural Development and Cooperatives (MoLGRDC) supervises the urban primary health care through city corporations and municipalities, where the primary health care centres (PHCC) are run by partner NGOs (5).

 

Fig. 1: Location of Bangladesh and Health service delivery organizational structure of the country (Source: Asia Pacific Observatory on Health Systems and Policies) (5)

 

Mental health in health service delivery :

In the health system of Bangladesh, unfortunately, there is no specific authority or commission  to operate or supervise the mental health service nationwide and no day treatment facilities for mental health care either. To talk about specialized hospitals, there is only one mental hospital available in the country for a total of 0.4 beds per 100,000 population. So, most of the patients seeking mental health care are managed in the usual health care service delivery system. Depression, schizophrenia and mood disorders are the most prevalent mental disorders there.

In general,  The national health care delivery system of the country is organized at three levels: Primary, secondary and tertiary health care which provides promotional, preventive, palliative and curative services. For care seekers, the pipeline of service delivery starts mostly from the outdoor patients department (OPD) or primary health care centres. Primary health care is the first level of outreach to the mass for primary care, which runs along with support from different NGOs, International donation and Public Private Partnerships (PPP). Secondary health care services are provided by district level hospitals, and are the first level of referral of cases beyond primary care facility, providing some specialist services. Tertiary health care is highly comprised with specialized services at regional or central level hospitals with additional services, such as teaching hospitals that are attached to medical schools.  

If we magnify the mental health facilities in the context, there are 50 outpatient mental health facilities in the whole country and only 2 of them are for children and adolescents, which facilitates only 26 care seekers per 100,000 population. Apart from those, the number of community-based psychiatric inpatient units and community residential facilities are 31 and 11 respectively, which doesn’t even serve more than one person in every 100,000 population. National Institute of Mental Health (NIMH)  is the only coordinating body dedicated to public education and awareness campaigns on mental health and mental disorders. Though the number of beds in the lone mental hospital in Bangladesh has increased by 25% in the last five years, it is still scarce. Most of the admitted patients there suffer from schizophrenia and rest mostly from mood disorder (2). Sadly, although it is the only mental hospital of the country, there is no reservation for children and adolescents, whereas studies showed that 10-20% of children and adolescents experience signs of mental disorders globally and half of all mental illnesses begin by the age of 14, and three-quarters during the mid-20s (6).

 

Barriers to mental health care seeking in Bangladesh:

There are a variety of factors inhibiting people to seek mental health care in Bangladesh, which both are dependent on individual, as well as societal factors. Social stigma, lack of relevant knowledge, and awareness seemed to play a major role. Most of neurotic patients do not prefer to consult or get admitted into psychiatric units due to social stigma, mental ward phobia, and poor maintenance of the working environment. Scarcity of health care facilities is another vital point, which is jeopardizing the mental health condition. Because of the limited resources and health care facilities, many people get deprived; accessibility and availability are two big issues there.

Inequity is profound at a large scale in the healthcare of Bangladesh. For example: distribution of beds is a barrier, which prevents the access for rural users and users from other religious, ethnic and linguistic minorities (7). A study showed that the density of psychiatrists around the largest city is 5 times higher than whole country (2).   In Bangladesh, health care services mostly depend upon out of pocket expenses, so does mental health care; only 0.1% patients get free services.  No mental disorder is covered in social insurance schemes either (8).

Mental health expenditures from government health department are less than 0.5%. Moreover, around 67% of all the expenditures spent on mental health are devoted to mental hospitals and rarely for further research and mental health promotion. Considering human resources, in every 100,000 population, the accompanying number of human resources involved is only 0.49.

 

Fig. 2: A  patient in the inpatient department of Pabna Mental Hospital during Photojournalist Allison Joyce’s visit. (9)

 

Fig. 3: “Tara B tried to commit suicide by hanging herself two years ago. Her family members put her in chains because she often ran away and harmed herself, and they feel they have no other choice.” – Photograph by Allison Joyce , Published in The Guardian. (9)

 

Initiatives in Bangladesh and the demand of the situation:

The mental health policy in Bangladesh was last revised in 2006, which is incorporated in policy, strategy and action plan for surveillance and prevention of Noncommunicable Diseases (NCD). Components like organization of services and developing community mental health services are included in the policy. It is crucial to include the mental health component in primary health care of the country. Human resources, involvement of users and families, advocacy and promotion, human rights protection of users, equity of access to mental health services across different groups, financing, quality improvement, monitoring system and researches are all part of the process. Currently, around 10 NGOs are working specifically in this field. One of them “kan pete roi” has begun to provide psychotherapy services over telephones to combat depression.  

 

From this scenario, we can assume the immense gap between demand and delivery of mental health services in Bangladesh. The situation requires strengthening of community based mental health facilities. It is only possible through expanding the existing training of primary health care physicians and primary health workers. Capacity and quality of existing outpatient and inpatient psychiatric facilities should have been widened. Private initiatives may be considered additional important steps for development of community mental health services. Most importantly, it is required to train the health professionals in mental health and raise awareness with promotional campaigns. People should be brought out of stigma and realize that it is a health disorder like other NCDs. The country needs a multi-sectoral integration. Despite limited resources, Bangladesh has always proven it’s ability to overcome public health challenges. We hope that the policymakers will pay their attention to the importance of the situation this time and that they won’t let the struggle become the identity.

 

 

References:

  1. icddr,b – News [Internet]. [cited 2017 Sep 23]. Available from: http://www.icddrb.org/news-and-events/news?id=710&task=view
  2. Bangladesh_WHO_AIMS_Report.pdf.
  3. Hossain MD, Ahmed HU, Chowdhury WA, Niessen LW, Alam DS. Mental disorders in Bangladesh: a systematic review. BMC Psychiatry. 2014 Jul 30;14:216.
  4. Countries by Population Density 2015 – StatisticsTimes.com [Internet]. [cited 2017 Sep 23]. Available from: http://statisticstimes.com/population/countries-by-population-density.php
  5. Ahmed SM, Naheed A, World Health Organization, Regional Office for the Western Pacific, Asia Pacific Observatory on Health Systems and Policies. Bangladesh health system review. 2015.
  6. WHO | Child and adolescent mental health [Internet]. WHO. [cited 2017 Sep 24]. Available from: http://www.who.int/mental_health/maternal-child/child_adolescent/en/
  7. Islam A. Mental Health and the Health System in Bangladesh: Situation Analysis of a Neglected Domain. Am J Psychiatry Neurosci. 2015;3(4):57.
  8. Islam A. Mental Health and the Health System in Bangladesh: Situation Analysis of a Neglected Domain. Am J Psychiatry Neurosci. 2015 Jan 1;3:57.
  9. The state of mental health care in Bangladesh – in pictures | Global Development Professionals Network | The Guardian [Internet]. [cited 2017 Sep 25]. Available from: https://www.theguardian.com/global-development-professionals-network/gallery/2015/oct/10/neglected-mental-health-in-bangladesh-pabna-mental-hospital-in-pictures

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