*Population in 2020、GNI and life expectancy are updated based on UN's 2019 data.

 *Medical information is based on WHO's report of 2017 Mental Health Atlas-country profile.

I.          Overview

　　People's Republic of Bangladesh, commonly known as Bangladesh, it is a country in South Asia and to face the Bay of Bengal in the south, and shares the border with India on three sides, except for the hilly area in the southeast which is adjacent to Myanmar. It covers the area of 147,570 square kilometers, and Dhaka is the capital and the biggest city of the country and is also the administrative center of the Dhaka Division. There are almost no highlands in the country and most of them are alluvial plains. Bangladesh has approximately close to169 million in population and 98% people speak Bengali. Among them, 89% of the persons believe in Islam, Hinduism accounts for 10%, and other minorities are less than 1%. The population ranks third in the world's Muslim countries, second only to Indonesia and Pakistan.

　　According to the Constitution of Bangladesh, all citizens are given the right to receive basic medical care services. However, the country's basic healthcare infrastructure is still poor. Medical facilities are mainly located in major cities, and almost no medical services are provided in rural areas.

　　The administrative regions of Bangladesh are divided into four levels, which are division, county, township and village. Only the division has the authority to set up local government, while the county, township, and village are the autonomous organizations. At present, there are 8 Divisions nationwide and under the jurisdiction, there are totally 64 counties (Zila), 490 township-level organizations (known as Upazila or Tana). The total health expenditure accounts for 3.41% of the gross domestic product (GDP) and the average national income in 2020 is 1,940 US dollars, while the expenditure on mental health takes the percentage about 0.5% of the total health budget.

II.        Mental health policy and system

　　Bangladesh does not have a clear mental health policy, the relevant policies and plans proposed in 2006 were only regarded as part of non-communicable diseases, and they could not provide sufficient resources for prevention, diagnosis and rehabilitation. This part might be a major challenge in the overall mental health field in Bangladesh. In order to improve the mental health system, the new Mental Health Act was passed in 2018 and replaced the Lunacy Act issued by the British colonial rulers in 1912. However, the new mental health act did not provide financial resources for the heavy burden of mental health care, and still ignores the privacy, rights and obligations, and human rights of patients with mental illness.

　　Bangladesh's medical system includes four main components: government departments, private organizations, non-governmental organizations, and international organizations. Government departments are responsible for proposing policies and managing health services, it is mainly implemented through the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP), which are under the Ministry of Health and Family Welfare (hereinafter called MoFHW). The two Directorates are to operate through the specialized hospitals affiliated to the medical school, county hospitals, and township hospitals (Upazila Health Complexes), as well as the villages and unions' Health and Family Welfare Centers, and community clinics to provide primary and secondary mental health care services.

Public health care services are divided into four levels:

 (1). Community-level medical care (provided by family medical care

       providers and community clinics)

  (2). Primary medical care (provided by rural medical centers, joint

        sub-centers, joint family welfare centers and Upazila health centers);

  (3). Primary/secondary medical care services (provided by district hospitals,

        general hospitals, chest clinics, tuberculosis clinics and leprosy

        hospitals);

  (4). Tertiary medical care (provided by teaching medical institutions,

        professional medical centers, medical hospitals and infectious disease

        hospitals).

　　Public medical care is heavily subsidized by the government, and patients need to pay a nominal fee, especially for outpatient care.

　　Although there is currently no health insurance system in the country, the Health Economics Unit (HEU) of MoHFW published a health care financing strategy for 2012-2032, which is to expand a Social Protection for Health towards Universal Coverage. The proposal is to cooperate with other domestic medical systems to solve financing challenges, and fulfil the process of gradual achieving universal coverage, which can be called the prototype of the country's health insurance. Because there are still a large number of poor families in the country, or those who are already in poverty are mostly burdened by bad health and out-of-pocket health care expense. Out-of-pocket expenditures account for 64% of total health budget, while government's expenses are about 26%, which seem unreasonable anyway. The fact is that the health care expenditures in Bangladesh account for 3.41% of GDP, while less than 1% of the population can be covered by insurance plans. In addition, due to demographic and epidemiological changes, non-communicable diseases are affected by the common infectious diseases and are becoming a major disease burden. This strategy provides a framework for the development and promotion of health financing in Bangladesh. The framework and its direction aim to improve the situation, ensure fair distribution of the burden of health financial resources, improve access to basic health services, reduce the incidence of poverty due to catastrophic health care expenditures, and improve service quality and efficiency.

III.     Human Resources

　　There are currently only a few psychiatric medical personnel in the Bangladesh psychiatry association (BPA), it is mainly composed of physicians, nurses, and psychologists. So far, there is no national organization or unit to be responsible for the provision and supervision of mental health services, and there is no day treatment facility either. The proportion of psychiatric specialists, nurses, and psychologists allocated to every 100,000 population is almost inside the last list among the "19 Countries in the Southbound Policy executed by Taiwanese government", and there is no social welfare network for social workers to provide services at all.

　　WHO pointed out that the ratio of various psychiatric professionals per 100,000 population in Bangladesh is still low, with psychiatrists at 0.13, nurses at 0.87, and psychologists at 0.12, respectively. There are no social workers and occupational therapists anyway.

　　The burden of mental illness in Bangladesh is extremely high but related care services are very few. In 2014, a study showed that the prevalence of mental illness among adults was 6.5-31.0%, while it was 3.4-22.9% for the children. About two-thirds of mental health expenditures are spent on psychiatric hospitals, with very little investment in the research and mental health promotion. Averagely, the proportion of mental health medical personnel is only 0.13% per 100,000 people.

　　Dhaka Medical College and Hospital (DMCH) is a public medical college and hospital located in the capital Dhaka. There are medical schools and tertiary hospitals in the campus, and is also a teaching hospital and a tertiary referral hospital with 2,600 beds.

　　The school offers Bachelor of Medicine and Bachelor of Surgery (MBBS) courses. The course lasts for 6 years, including 5 academic years and 1 year internship. The five academic years include four stages, namely the first stage of anatomy, physiology and biochemistry (1.5 years); the second stage (1 year) for forensic medicine and community medicine; the third stage (1 year) for the pathology, microbiology and pharmacology; the fourth stage (1.5 years) in pharmacology, surgery and gynecology, and then to follow a year of clinical internship. In the past, during the 1-year internship preparation period, psychiatric training was not mandatory and it only provides 5 days of non-compulsory participation opportunities. Although most medical students will complete clinical internships, they lack practical experience in interacting with patients with mental disorders anyhow. In 2012, Bangladesh Medical and Dental Council (BM&DC) revised the existing curriculum, in the third stage, it required a three-week ward practice training for the clinical course of psychiatry. In addition, in the final stage, 20 hours were allocated in each 20 teaching lectures. During the preparation for the final exam, an additional 3 days of job referral opportunities will be arranged.

　　At the end of each stage, a professional examination will be conducted. After passing all the professional examinations, students can receive an MBBS degree.

IV.    Mental health care system and health promotion

　　Upazila Health Complexes (UHC) include community clinics, family welfare centers and other units, with a scale of about 31-50 beds. UHC is usually provided by non-governmental organizations (NGOs), international donations, and public-private partnerships.

　　Secondary care is a general hospital with a scale of 100-250 beds and a hospital affiliated to a medical school. It is generally located in a county-level administrative area and is usually the first line referred by primary care institutions, providing some specialized services. As for the eight administrative regions of municipalities directly under the Central Government, there will be 250-1050 beds of teaching hospitals or medical school affiliated hospitals in the capital or metropolitan area.

　　There are 50 psychiatric clinics in the country, of which only two provide services for children and adolescents. This number means that only 26 people per 100,000 population seek psychiatric outpatient services. There are 31 and 11 psychiatric hospitalization and community residential services, respectively, which does not reach the standard of 1 person per 100,000 people.

　　In addition, mental health services in Bangladesh need to be fully self-financed. The high medical expenses affect the willingness to seek medical treatment, and also cause heavier mental illness and becomes the burden of family members.

　　There are three levels in the government health care system, and the provision of mental health services is limited to tertiary hospitals. Currently, there is only one specialized hospital providing inpatient services, with only 0.4 beds per 100,000 population. Therefore, mental health services or treatment for mental illnesses are required under the general health service system. The most common mental illnesses are depression, schizophrenia and affective illness. The National Institute of Mental Health is the only unit that conducts health education and detection of public mental health and mental illness. Even if the number of psychiatric beds in Bangladesh has increased by 25% in the past five years, the overall shortage remains. Furthermore,    the psychiatric hospitals for the general public are still in a state of inadequate use and its equipment are mostly outdated. In the only psychiatric hospital, there is no psychiatric service for children and adolescents.

　　The Bangladeshi Mental Health Forum (BMHF) is a charity established in 1999, it aims to promote the mental health of the community to raise people's mental health awareness, strive for better and more appropriate mental health services for the community, and provide a support network for mental health workers in Bangladesh.

The main goals and mental health promotion activities of BMHF in the community include:

      (1). Raise people's awareness of mental health in the community

      (2). Challenge the stigma and try to wash away stereotypes and prejudices;

      (3). The importance of education and advocacy of mental health;

      (4). To organize mental health awareness activities and workshops;

      (5). Promote and advocate various activities to improve access to mental health services;

      (6). Cooperate with service provider hospitals to meet the needs of patients and nursing staff in Bangladesh;

      (7). Concern for the family of the service provider, the patient himself, the caregiver and the community;

      (8). Participate in formal mental health strategy meetings and forums on behalf of the Bangladeshi community;

      (9). To facilitate activities and signposting services in the community.

V.       Major issues, challenge, and opportunities

　　In Bangladesh, social stigmatization of mental illness, lack of relevant knowledge and awareness are the main factors that hinder the people in seeking mental health care. As a result, most patients with mental illness do not like to consult or live in a psychiatric ward and feel panic in there (Mental Ward Phobia). For those people, it will have difficulty maintaining their works.

　　There are two serious problems in Bangladesh's health care system. One is the low accessibility and availability of resources and health care institutions, so there leads to a lack of care institutions. The second is the uneven distribution of resources, like the distribution of beds, which restricts the use of disadvantaged ethnic groups in rural areas and other religious races with different languages. Studies have shown that the density of psychiatrists in the largest city in Bangladesh is five times the national average, still there is no psychiatrist in many areas.

VI.    Potential exchange issues

The current challenges facing psychiatric care in Bangladesh are as follows:

      (1). Insufficient training manpower and too little capacity;

      (2). Difficulty in referral;

      (3). The continuity of training and service;

      (4). There is a huge gap between urban and rural areas, and there is a serious

            shortage of rural resources;

      (5). Difficulties in integration with hospitals at all levels.

　　The gap between the demand and supply of mental health services in Bangladesh requires to strengthen community-based mental health institutions by expanding the capabilities of existing primary-level medical doctors and medical staff. Moreover, the capacity and quality of existing psychiatric outpatient and inpatient services should be enhanced, and the participation of private institutions can be used as the next step in the development of community mental health services. More importantly, it is necessary to train mental health professionals and improve the ability of medical staff to perceive the symptoms of mental illness. In addition, we need to eliminate disease stigma and let the public understand that this is the same health problem as other non-communicable diseases. Although resources are limited, the performance of Bangladesh in public health is obvious internationally, and it is hoped that inter-departmental integration will allow mental health to have the same outstanding performance.

　　In summary, the training of psychiatric staff, the model of community mental rehabilitation, and the diagnosis and treatment for children and adolescents are all potential topics for future exchanges.