|POLICY AND PRACTICE
|Year : 2012 | Volume
| Issue : 3 | Page : 339-346
Mental health care in Bhutan: policy and issues
Registered Nurse Midwife, Jigme Dorji Wangchuk National Referral Hospital, Thimphu, Bhutan
|Date of Web Publication||25-May-2017|
Registered Nurse Midwife, Jigme Dorji Wangchuk National Referral Hospital, Thimphu
The Royal Government of Bhutan pursues and promotes a policy of providing well integrated, equitable, cost-effective and balanced health services consisting of preventive, promotive, curative and rehabilitative programmes through its primary health care system. The government has accorded high priority to social sectors like health and education. However, there are serious concerns regarding the quality of care provided to persons with mental disorder, who on this account are subjected to stigma, discrimination and human rights abuses. This article aims to analyse, examine and highlight the policy and issues of the mental healthcare system in Bhutan. It focuses on the mental healthcare system with reference to services, policies and issues and to advocate for better policy development for mental health.
Keywords: Bhutan, mental health, health policy, health system, access to health care.
|How to cite this article:|
Pelzang R. Mental health care in Bhutan: policy and issues. WHO South-East Asia J Public Health 2012;1:339-46
| Introduction|| |
Bhutan is a small kingdom with an area of 38 394 square kilometres and a population of 672 425. It is landlocked in the eastern Himalayas and is almost entirely mountainous with land rising from 180 metres above sea level in the south to 7550 metres in the north. Bhutan is a country with immense diversity in language, levels of literacy, and social and cultural practices.
Organizing mental health services for this predominantly scattered population with diverse cultural practices is indeed a daunting task. This issue is further compounded by low financial resources, scarcity of mental health personnel, lack of comprehensive mental health policy, presence of conflicting healing systems and the stigma of seeking help for the mentally ill. This article looks at the mental health care system in Bhutan with respect to its services, policies and issues.
| Prevalence of mental disorders in Bhutan|| |
Though very little reliable data is available on mental illness in the country, more than 2846 new cases of mental disorders were treated at the National Referral Hospital (NRH) in 2008. Of these, 29.3% suffered depression, 19.2% anxiety disorder, 9.7% psychosis and 41.5% were alcohol/substance abuse related and mental retardation. Mood disorders (32%); mental and behaviour disorders due to substance use including alcohol (27%); neurotic, stress-related and somatoform disorders (17%); and schizophrenia (19%) were the primary diagnosis of patients treated in the community mental health outpatient facilities. Fifty per cent of those attending community health centres were female.
| National mental health programme and policy|| |
The National Mental Health Programme (NMHP) was started in July 1997 with the objective of ensuring the availability and accessibility of primary mental healthcare for all sectors of the population by integrating mental health in general healthcare. With policies of integration of mental health in general healthcare, the status of the people with mental disorders depended largely on public healthcare programmes in the areas of general healthcare.
The NMHP sought to integrate mental healthcare with the PHC system by training personnel at primary healthcare centres. It was envisaged that integration of mental health into the PHC system would enable patients to receive both physical and mental care simultaneously in one visit by reducing the stigma associated with mental illness. The integration of mental health in PHC helped to create mental health awareness in the community.
| Organization of mental health services|| |
Mental healthcare in Bhutan is integrated into the PHC system to provide essential mental healthcare to patients in their homes and community, hence providing a community- oriented approach. Mental healthcare is delivered through the system of a four-tiered health care system [Figure 1].
| Community mental health facilities|| |
There are 63 community-based psychiatric units in the country with a total of 100 beds or 14.9 per 100 000 population and are fully integrated with the general healthcare services. However, none of the community mental health facilities have trained psychiatrists. Primary care physicians and community health workers are responsible for managing the patients in their settings. Patient admission is both voluntary and involuntary.
All 63 facilities have at least one psychotropic medicine of each therapeutic class (anti- psychotic, antidepressant, anxiolytic, and mood stabilizer). Separate community mental hospitals, residential and forensic facilities are not available as of now. Further, there are no private mental healthcare facilities available in the country.
| Issues in providing quality mental health services to patients|| |
Bhutan has made significant strides at the level of policy, thus bringing the country in line with other countries around the world that have made similar efforts at integration. However, there have been a number of issues and challenges at the level of implementation. The pressing issues that need to be addressed urgently are discussed below [Table 1].
Funding of mental health services
One of the policies of NMHP is to provide adequate care for individuals with mental disorders. However, the lack of funding remains a key issue to the provision of adequate mental health service in the country.
The government spends 10% of the gross domestic product for health services, of which only about 1% of the total health expenditure is directed towards mental health. The fact that mental illnesses are an emerging issue in Bhutan, allocation of adequate funds is necessary to provide the best standard of care to people with mental illness. For this, policy makers need to take into consideration the cost-benefit analysis of treating persons with mental illness and accordingly allocate sufficient funds for mental healthcare in order to make the healthcare services viable and sustainable.
Mental healthcare resources
To provide quality mental health care to the population, it is essential that an effective organization for mental healthcare is in place. Bhutan currently lacks proper infrastructure, mental health professionals and adequate supply of medicines. There is only one mental health inpatient ward which is solely for adults, two psychiatrists (less than 0.3 per 100 000 population) and three trained psychiatric nurses (less than 0.4 per 100 000 population) to cater to approximately 0.7 million people. There are no psychologists, social workers and occupational therapists. Further, access to psychotropic medications is very limited in the community health centres. The basic resources for mental health care in Bhutan are obviously inadequate.
Since the way in which mental health services are organized affects treatment coverage for people with diverse mental disorders,, a three-level mental illness treatment, rehabilitation and prevention network should be established in the rural community, which connects the district, sub-district, and village. Resources such as community crisis centres, ambulatory services, and financial and personnel resources need to be invested in the community. Further, development of psychiatric specialties within regional referral hospitals is necessary to treat acute mental illnesses. Subsequently, it is desirable to encourage nongovernmental organizations to establish mental health service facilities to supplement the government's efforts.
In order to set up such a mental health system and strategy, policy makers should be able to synthesize the unique situation of the country to consider the priorities, sustainable development and the effectiveness of the plan.
A large proportion of the unmet need for mental health services arises from the limited ability of physicians and PHC workers in general health settings to recognize and treat psychological problems of their patients. A policy laying down a minimum standard of mental health services to the people in the community needs to be formulated with the focus on advanced training on mental healthcare and complemented by a recruitment scheme by the health department to address the disproportionate workforce. The policy should aim at improving the efficiency of PHC workers in mental healthcare by providing adequate time for psychiatric training in medical education. Further, it is essential to train and recruit psychologists, social workers and occupational therapists to provide a minimum standard of mental healthcare to the people.
While the issue of access to psychotropic drugs in community health centres is a difficult and complex one, the problems relating to medicines for mental illness are partly due to poor purchasing and utilization. The policy must be aimed to improve the access to safer and more efficacious medications by developing policy guidelines on proper purchasing and utilization of medicines.
Alternative healing practices
In Bhutan, people's attitudes towards mental illness are strongly influenced by traditional beliefs. Mental illness is believed to be caused by black magic, evil spirits, witchcraft, a curse, or ‘karma’ of previous life. These views and attitudes contribute to stigmatization and discrimination of the people with mental disorder. Further, people often think that mental illness is largely incurable. As a result most people resort to alternative healing practices, especially religious/faith healing. It is presumed that more than 99% of the people seek religious help when someone is sick physically or mentally.
Improving mental health literacy and awareness among the public should be given priority in the development of mental health policies as many aspects of mental healthcare require the active collaboration of the community. The lack of mental health knowledge influences the attitude of the public and leads to prejudice and discrimination which, in turn, lead to unjust treatment being meted out to patients with mental illness., Therefore, it is necessary to develop a strategy to encourage the use of the mass media to publicize mental health knowledge vigorously. Further, the mental health movement needs to be started as a partnership between the patient, the family, the professionals and the community to understand and offer support to mental health in the country.
These strategies can be an integral part of any progressive mental health programme, contributing to both educating and supporting the public in the field of mental health. Public education through print, electronic media and mental health movements help to de-mystify mental health issues, and go a long way to reduce prejudice and discrimination against mental illness.
In the case of people resorting to religious care, it is essential for policy makers to be aware of the need to provide a sound and workable approach for integrating traditional and religious care in mental health service delivery. Integrating traditional and religious care would potentially alleviate some of the myths and misconceptions that are attached to modern medical treatment. This would also promote ethical care and encourage a more holistic approach to mental healthcare.
Research and information system
For the successful integration of mental health services in the PHC system, a reliable and valid database on the prevalence of common mental disorders in the community is essential. The challenge for Bhutan is to generate empirical evidence as a basis for policy formulation. The mental health policy needs to be based on evidence and understanding of the grassroots level situation. The data will not only guide the planning, intervention and resource allocation in the area of mental health but also help develop the required methods of planning and intervention.
The collection of basic statistics is lacking and inadequately implemented. Questions about the prevalence of common mental disorders are largely unanswerable. For this, the development of proper information systems to monitor and review the common mental disorders in the country is essential. Further, epidemiological research on mental illness is necessary to understand the prevalence of mental disorders in the country. Evidence-based planning, decision making and practice will help to improve the efficiency of resource allocation and improve the health status and quality of life of people with mental health problems.
Mental health legislation
In Bhutan, admissions of the mentally ill to hospital are both voluntary and involuntary. A majority of patients are brought to hospital by families and relatives for treatment. Only a few are brought from the criminal justice system or from prison.
As of now, Bhutan does not have any mental health legislation to protect the rights of people with mental illness. There are no clear policies to prevent unlawful institutionalization, coercive medications/ therapies and inappropriate detention for psychiatric evaluation in the absence of psychotic symptoms.
The international human rights movement has become an increasingly important source of protection for individuals with mental disorder around the globe. Mental health legislation which ensures equity of access to mental healthcare is necessary. A Mental Health Act must be enacted as soon as possible in Bhutan to protect the legal rights of patients with mental disorders. Inherently, mental health legislation should be enacted, aligning the provision of mental health services with the country's constitution, which obliges to protect human rights in Bhutan.
To protect the safety and well-being of society, legal provisions must be explicit about the conditions to be met before a mentally ill person can be compulsorily admitted and treated. Further, legal provisions for the protection of the mentally ill from unjust and discriminatory treatment ought to be adopted.
| Delivery of mental health and social services|| |
An important part of mental healthcare in Bhutan is the close relation between the level of mental health in the community and the general level of social well-being. It is important to consider mental health promotion in the policies and plans of all agencies of the government, from health and education, to justice, transport, environment, housing and welfare. Prevention and promotion of mental health depends on the ability of health policy to build effective partnerships with the range of agencies which can contribute to improving local mental health.
Of particular concern to healthcare planners is the increase in the number of cases of substance use disorders admitted to hospitals. The high prevalence of substance use disorders indicates that the mental health consequences of substance use disorders will loom large in the overall mental health morbidity for many years to come. Mental health policy in Bhutan should take into account the demands of substance use- related morbidity in the mental healthcare plan. It should include a strong component of measures that can reduce the substance use in the country and particular attention given to prevent substance use and related harm among people through effective health promotion strategies implemented in school, family, peers, community and the media. Further, separate treatment and rehabilitation facilities for substance use disorders need to be established and the PHC professionals should be trained in the management of substance use disorders in the community.
| Conclusion|| |
Mental illness is becoming a public health issue in Bhutan. The number of people with mental illness requiring care is increasing. Besides, there has long been a tendency to neglect the care of persons with mental disorder in the general setting; the reason being the lack of understanding and poor management of mental illness by the health professionals and people. It is also because Bhutan devotes a much smaller proportion of health resources to mental healthcare.
To strengthen mental healthcare in the country, mental health awareness should be integrated into all elements of health and social policy, health-system planning and healthcare delivery. Essentially, mental health policy in Bhutan needs to be based on a wider range of evidence.
| References|| |
Nirola DK. Where psychiatrists are scarce: Bhutan. Asia Pac Psychiatry
. 2010; 2(3):126.
World Health Organization, Country Office for Bhutan. WHO-AIMS report on mental health system in Bhutan. Thimphu: WHO and Ministry of Health, 2007.
Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. The Lancet
. 2007 Sep 29; 370(9593):1164-74.
|6.|Organization of services for mental health: mental health policy and services guidance package
. Geneva: World Health Organization, 2003.
Liu TQ, Ng C, Ma H, Castle D, Hao W, Li LJ. Comparing models of mental health service systems between Australia and China: implications for the future development of Chinese mental health service. Chinese Med J
. 2008; 121(14): 1331-1338.
Ustun TB, Sartorius N. Mental health in general health care: an international study
. New York: John Wiley & Sons, 1995.
Gureje O, Alem A. Mental health policy development in Africa. Bulletin of the World Health Organization
. 2000; 78: 475-482.
Pelzang R. Attitude of nurses towards mental illness in Bhutan. Journal of Bhutan Studies
. 2010; 22(3): 60-77.
Pelzang R. Religious practice of the patients and families during illness and hospitalization in Bhutan. Journal of Bhutan Studies
. 2010; 22(4): 77-97.
Gureje O, Lasebikan VO, Ephraim-Oluwanuga O, Olley BO, Kola L. Community study of knowledge of and attitude to mental illness in Nigeria. Br J Psychiatry
. 2005; 186: 436-441.
Gureje O, Lasebekan VO. Use of mental health services in a developing country: results from the Nigerian survey of mental health and well-being. Soc Psychiatry Psychiat Epidemiol
. 2006; 41(1): 44-49.
Knapp M, Funk M, Curran C, Prince M, Grigg M, McDaid D. Economic Barriers to better mental health practice and policy. Health Policy Plan
. 2006 May; 21(3):157-70.
Faunce TA. Collaborative research trials: a strategy for fostering mental health protections in developing nations. Int J Law and Psychiat
. 2005; 28(2):171- 181.
Maxwell M, McCollam A. Mental health and wellbeing at primary care level in Scotland: a vision for community health partnerships. Mental Health Review Journal
. 2004; 9(4): 25-28.
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