|
*Population in 2020、GNI and life expectancy are updated based on UN's 2019 data. *Medical information is based on WHO's 2017 report Mental Health Atlas-country profile. |
I. Overview |
|
Federal Democratic Republic of Nepal is a landlocked country in the Himalayas region of South Asia, it shares the border with China at the north, and India is the neighborhood of its three other sides. At the southeast tip, it is only 27 kilometers close to Bangladesh (Siliguri corridor). Due to its high altitude, eight of the ten highest peaks in the world are located in or on the border of Nepal including the highest peak Mount Everest, so it is also a tourist attraction for mountain climbers. Nepal has many ancient cultural heritages with UNESCO certification, and one of them is the birthplace of Buddha Shakyamuni (at Lumbini) who is the founder of Buddhism. The main religion of the country is Hinduism, and it had 80.6% of the population in 2001; the rest were Buddhists (mostly Tibetan Buddhism) 10.7%, Muslims 4.4% and primitive religion 3.6%. The current population is about 29.13 million, and the land area is 147,181 square kilometers. The life expectancy at birth is averagely 70.8, of which 68.88 are for men and 72.75 for women. Nepal's national income per capita in 2019 was US$1,090, and the total health expenditure accounted for 5.81% of its GDP. The World Health Organization (hereinafter called WHO) estimates that neuropsychiatric illness in Nepal occupy 11.0% of the global disease burden. According to the Constitution of Nepal, which was promulgated on September 20, 2015, the original five Development Regions and 14 Special Districts were revoked. Instead, the whole territory were re-partitioned into seven provinces (first-level administrative units), and there were totally 77 districts under these seven provinces. Each district is managed by a district coordination committee basically. The capital- Kathmandu, which is located at the center of the Bagmati province (old name as the Third Province) with a sea-level of 1,400 meters high, is a culturally historic city in the country. The current healthcare is organized as a hierarchical referral system. There are community health units, health stations, urban health centers, and primary hospitals (including primary health centers). More complicated and severe cases will be referred to secondary or tertiary hospitals (provincial level and above) and 8 specialized hospitals. The Ministry of Health and Population (hereinafter called MoHP) formulates and supervises the overall health policies/plans, monitors and evaluates health activities and results. In 2018, the Epidemiology and Disease Control Division (EDCD), which is under the Department of Health Services (DoHS), was designated as the key unit responsible for overseeing mental health in Nepal. The country’s mental health plan is implemented by the Non-communicable Diseases and Mental Health Division. |
II. Mental health policy and system |
|
Nepal formulated a mental health policy in 1996, but there is no mental health legislation yet. A draft was issued in 2018 and under review by the MoHP. The five key strategies of the draft are: (1). Ensure the best mental health services for all the population in Nepal; (2). Ensure the management of necessary human resources and other resources to provide mental health and psychosocial services (3). Raise awareness of mental health, uncover the mystery of mental illness, reduce related stigma and promote mental health; (4). Protecting the basic rights of patients with psychosocial disabilities and mental illness; (5). Research to promote and manage health information systems and mental health projects. In terms of the national health budget, as of 2020, only about 0.2% of health care expenditures are spent on mental health. There is no human rights audit agency to inspect mental health facilities and impose no sanction on facilities that continue to violate the rights of patients. Mental health is one of the health care areas that have received the lowest attention in Nepal, and less than 1% of the government’s health care expenditures are for the mental health. Nowadays, most people choose traditional therapists. If ineffective, they will go see the psychiatrist finally. There are only few psychiatrists in Nepal, however, a large number of psychiatric patients make hospitals overcrowded and difficult to have the quality services. In fact, there are very few trained psychologists work in private clinics or in government hospitals. Most psychiatrists only work in Kathmandu, and there are approximately 25 private psychotherapy centers in there. WHO's Mental Health ATLAS 2017 pointed out that Nepal still had no health insurance system, and the mental health care expenses would be paid by the people in full amount. The government has already embarked on a plan to promote the health insurance in some ways. The Health Insurance Board (HIB) is a social protection plan by the Nepalese government, which aims to enable citizens to obtain quality healthcare services without financial burden. Families, communities and governments directly participate in the plan, to combine prepayments and risk sharing with mutual support to help prevent people from falling into poverty due to health care costs, i.e., catastrophic expenditures lead to accidents or illnesses. The plan also promotes high-quality health services, which seeks to resolve barriers in the use of them, and to ensure fairness for the accessibility to the poor and disadvantaged groups as a means of achieving universal health coverage. |
III. Human Resources |
There is only one mental health hospital in the country, and the services are not easily accessible in rural and remote areas. However, there is a network that can integrate mental health in the general health service system, and people’s awareness of it is gradually increasing, so the number of people seeking treatment in mental health institutions is gradually increasing. The accessibility of psychiatric medicines has also increased a lot in recent years, which have been included in the "essential medication list" of primary care. There are few mental health professionals in Nepal, and the total number of people working in mental health facilities, including the private sector, is 0.59 per 100,000 people. According to the report of the WHO Mental Health System Assessment Tool (ATLAS 2017), the proportion of various psychiatric professionals per 100,000 population in Nepal is still low, with psychiatrists 0.36, nurses 0.56, and psychologists 0.52. , There is no manpower information for social workers and occupational therapists.
According to the mental health human resources report provided by the Nepal Health Network, please see the following Table 1.
In 2000, the government's funding for health affairs was approximately US$2.30 per person per year, and about 70% of health expenditures came from donations. The government's funding for health is about 5.1% of the 2004 fiscal year budget, and foreign donors account for about 30% of the total health budget.
2% of the training fee provided for physicians is dedicated to mental health training, and the nurses also have the same percentage. In 1978, Nepal's historical and largest Tribhuvan University launched the country's first medical degree program to help solve the shortage of the doctors. As of October 2020, Nepal had summed up 23 medical schools (with 17 private ones), including schools affiliated to Tribhuvan University and Kathmandu University, as well as independent medical schools such as BP Koirala Institute of Health Sciences and Patan Academy of Health Sciences. In total, these schools have trained more than 1,500 medical graduates each year. However, Nepal lacks a clear policy for the establishment of medical schools. Many medical institutions focus on increasing financial profits instead of providing quality education. In addition to the scarcity of technology and infrastructure, the skilled health care personnel are insufficient. Anyway, their medical education still has room for improvement.
In addition to the current COVID-19 pandemic, the global medical education model is undergoing major changes, due to the travel restrictions, social distancing, other lock-in measures, etc., that have led to the closure of related institutions, thereby, medical educational and teaching methods are forced to shift to online learning. Nepal's shortage of Internet infrastructure has seriously affected the cultivation of its medical talents. Starting in March 2020, some of the medical schools have suspended physical courses and clinical rotation training for students.
IV. Mental health system and health promotion |
Mental health services in Nepal start from general hospitals. Rajankar in Lalitpur is the only psychiatric hospital with a capacity of 50 beds. Mental health services are provided by psychiatric units in medical schools, provincial hospitals, and some private hospitals. There are 25 psychiatric inpatient facilities with total 500 beds. It sets up the clinics in different subspecialties such as children, memory, headaches and addictions. The Child and Adolescent Psychiatry Department in the Kandy Children’s Hospital is the only full-time outpatient clinic for children in Nepal, and there is no dedicated children’s inpatient department at present.
One of the obstacles for the development and provision of mental health care is the lack of social welfare nets. In Nepal, most mental health care is paid by out-of-pocket. However, the DoHS's 2075 Basic Health Service Package (since 2018) had recently included the depression, psychosis, alcohol use disorder, and epilepsy in its scope, i.e., the care and treatment of these diseases would be free. The medications had included diazepam, amitriptyline, chlorpromazine, trihexyphenidyl, phenobarbital, carbamazepine, sodium valproate, risperidone, thiamine, etc. According to data of 2003, Nepal had 10 health centers, 83 hospitals, 700 health stations and 3,158 "sub-health stations", and 1,259 health doctors to serve for the village areas.
As of 2011 data, there were 102 hospitals in Nepal. The status of health care services、sanitation、nutrition and hygiene facilities are poor in quality, and cannot cover a large proportion of the population, especially in rural areas.
A non-governmental organization is running community mental health services in 7 of the country's 77 districts. In other areas, because the said services have not been integrated into the general health service system, community related services cannot be provided. The country's overall mental health infrastructure is weak, and human resources are insufficient to meet the demand. At present, most psychiatric wards are cared by general nursing staff, and neither mental health service staff nor inpatient psychiatric working staff have received special training on related mental health or mental disorders.
The National Mental Health Self Help Organization is a non-governmental and non-profit organization, which committed to Nepal's mental health issues and had been working informally in the field of mental health since 2004. It adopts a double-track approach by simultaneous executing publicity、awareness programs and service delivery. It emphasizes the mental health services and the prevention by adopting a public-private partnership approach. Community-based mental health plans shall include:
(1). Mental Health Gap Action Program (MHGAP): Follow the MHGAP model developed by the WHO to ensure the provision of mental health services by the primary health care sector and to seek more services for the people with mental health problems. The Self Help Organization cooperates with the local government and community hospitals to provide mental health outpatient
services、drug services and psychosocial counseling in its work area.
(2). Self-help and Peer Support groups: Encourage people with mental health problems to form self-help groups (SHG), and to assist in the management of the said groups. Let people with mental health problems gather together to share knowledge and experience, and help each other with emotional and practical social support.
(3). Emergency Support: Provide emergency relief assistance for abandoned women suffering from mental health problems, with the purpose of rescuing, offering the necessary treatment, and ultimately facilitate their reintegration into the society.
Table 2 shows mental health services and resources in Nepal.
V. Major issues, challenge, and opportunities |
|
According to estimates from the MoHP of Nepal, about 15-20% (2 to 3 million) of the national population may suffer from some forms of mental disorders. Mental health is largely affected by social、economic and environmental factors. According to research, the global prevalence of mental disorders in children and adolescents is about 10% to 20%. Similar types of disorders exist in different cultural groups, such as anxiety disorders, behavioral disorders, and mood disorders. In Nepal, 40% of the population is under the age of 18, and a large proportion of it is at the risk of developing mental disorders. Nepal has recently recognized the severity of mental health problems in children and adolescents, and has begun to pay attention to identifying and treating their mental disorders, and its severity is still unclear. The reasons are the lack of the related mental health policies and the poor services for them. In addition, Nepal does not have specialized psychiatry research training in this field, and the research conducted so far is limited. Since the government's mental health budget accounts for less than 1% of the total health budget as mentioned, it can thus be understood the expenditure for the children and adolescents' mental health services has an even smaller proportion. Nepal’s 2020 National Mental Health Survey report stated that the prevalence of mental distress among adolescents (13-17 years old) was 5.2%, and the depression rates of men and women were similar. Other mental health challenges include the shortage of adequate mental health professionals and treatment facilities, weak mental health infrastructure, and insufficient human resources to meet the requirements. Currently, most psychiatric wards are allocated and managed by general nursing staff, whose specialized training in mental health are not enough. The government structure for mental health issues is not yet in place, although legislation has been planned for years, there is currently no Mental Health Department in the MoHP, and the budget for its services is inadequate. The main problems that need to be overcome are to carry out the community services properly, the reduction of high suicide rates, the destigmatization of mental illness, the relief for financial constraints, the speed-up in passing the required mental health law and appropriate use of human resources. |
VI. Potential exchange issues |
|
Nepal may have serious mental health problems for children and adolescents. Moreover, the main issues of mental health care and therapy in Nepal include lack of infrastructure, insufficient mental professional manpower, inadequate mental health training for primary medical staff, and the shortage of services at all levels of medical care. The topics of future exchanges shall cover the psychiatric medical care for the young, psychiatric manpower training, and primary care and enhancement for community mental rehabilitation models. |