*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

　　Islamic Republic of Pakistan, a federation system known as Pakistan, is the second largest country in South Asia and the fifth most densely populated area in the world with a population more than 220 million people. For the number of religious people, Pakistan ranks No 2 (second only to Indonesia) in the world with its Muslim population. The proportion of people under the age of 18 is 45%, while the proportion over 60 is only 4%, but nearly 30% of the population lives in poverty.

Pakistan, with an effectively controlled land area of 881,913 square kilometers, is located at the junction of the Arab, Eurasian and Indian plates, and three-fifths of the country are mountains and plateaus. There are the Himalayas in the north, the Hindu Kush mountains in the northwest, the alluvial plains in the middle and lower reaches of the Indus River in the east, and part of the Thar Desert in the southeast. It is divided into three major geographic regions, including the northern highlands, the Indus Plain, and the Balochistan Plateau.

　　Administratively, it is divided into four provinces and 1 district, and Kashmir area including Azad Jammu and free Kashmir, and a temporary province-Gilgit-Baltistan. The four provinces are Balochistan, Punjab, Sindh, and Khyber Pakhtunkhwa, while 1 district is the Islamabad Capital Territory.

　　The per capita national income in 2019 was US$1,410, and the World Health Organization (hereinafter called WHO) pointed out that the country’s national health expenditure accounted for 2.62% of the gross domestic product. According to UN data, the average remaining life at birth in Pakistan is 65.6 years old. It is estimated that its neuropsychiatric diseases account for about 11.9% of the global disease burden.

　　The central health authority is the Ministry of National Health Services Regulations and Coordination (MoNHSRC), which provides the Health Services、Regulations and Coordination, and committed to helping the people of Pakistan maintain and improve their health and make the people healthier.

　　The National Institution of Health (NIH) is one of the most prestigious health institutions in the country. It has been engaged in multidisciplinary public health-related activities such as diagnostic services, research and production of various vaccines for more than 40 years. In 1980, the President awarded NIH a grant as the status of an autonomous organization in the country, and to promote international and regional cooperation, to seek more effective technical assistance, and to participate in global disease control procedures.

II.       Mental health policy and system

Pakistan’s earliest mental health policy was launched in 2001 and revised in 2003 which include the following components:

(1). Develop community mental health services

(2). Manpower reduction in large psychiatric hospitals

(3). Develop mental health components in primary health care

(4). Human resources

(5). Participation of users and families

(6). Publicity and promotion

(7). Human rights protection for users

(8). Equal access to mental health services

(9). Financing

(10). Monitoring system.

　　In addition, a list of essential drugs including antipsychotics, antidepressants, mood stabilizers and antiepileptics had been drawn up. This revision could be regarded as a great leap forward in the country's mental health care, including reforming mental hospitals to provide more comprehensive care and to improve quality. At the same time, the budget, the timetable and specific goals of the final mental health plan were formulated.

The 18th amendment of the country's constitution had delegated the responsibility of health to the provincial government, and it became the task of each province to formulate appropriate mental health regulations, which would later be enacted by their respective parliaments. The current mental health legislation is not ideal, and only Sindh and Punjab have enacted their own mental health laws.

　　Pakistan launched the Prime Minister's National Health Insurance Program (PMNHIP) on December 31, 2015, which aimed to provide health insurance for families living below the poverty line in the country (for families with a daily income of less than 200 Rupees). The plan would be funded by 1 billion Rupees ($9.5 million, at that time) in the central government budget and provincial budgets, and would be operated through the State Life Insurance Corp. of Pakistan. It provided medical cards for poor families to cover up a maximum to 50,000 Rupees ($477, at that time) in public or private hospitals, including emergency, obstetric care, post-discharge treatment and even transportation expenses. In addition, they would receive insurance up to 300,000 Rupees to cover the treatment of seven particularly expensive diseases, i.e., diabetes, cardiovascular disease, cancer, kidney and liver disease, AIDS and hepatitis complications, burns and traffic accidents. Its overall goal was to provide 100 million people with medical insurance within ten years. However, according to the economic survey by the Ministry of Finance, from 2007/08 to 2013/14, total public health expenditures (including federal and provincial expenditures) grew by 29% annually. The Economist Intelligence Unit (EIU) predicted that the total medical expenditure would rise to about 3% of GDP from 2016 to 2020, which had become a hidden worry for the country's future finances. (Remarks: In October 2021, the currency 1PKR=0.16396 NT$.)

III.     Human Resources

　　According to the country’s public mental health professionals, Siham Sikander, an associate professor at the Islamabad School of Health Services, issued a Pakistani study published in the journal Lancet in October 2020. Pakistan, with a population of 200 million, is one of the countries with the worst mental health indicators, the psychiatrists are fewer than 500. The treatment gaps caused by the lack of mental health professionals has resulted in 90% of patients with common mental illnesses not being treated.

　　There are approximately 400 qualified psychiatrists in Pakistan. Most psychiatrists work in cities, and regional psychiatrists positions have also been established across the country. Although the country’s major centers are developing multidisciplinary services, in general, psychiatrists work single-handedly.

　　Medical education in Pakistan is provided by more than 50 medical schools across the country. Among them, 27 are affiliated with the University of Health Sciences (UHS) in Lahore. Medical education is Bachelor of Medicine and Bachelor of Surgery (MBBS). The courses need five years, the first three years focusing on basic medical sciences, such as human anatomy, physiology, biochemistry, general pathology, and pharmacology, while the remaining two years are dedicated to clinical training in medicine, surgery, gynecology, pediatrics, otolaryngology and ophthalmology. Graduates who have completed five years of medical education must complete another year of specialized clinical training called "House Job", only then can it be recognized as a registered doctor by the Pakistan Medical and Dental Council (PMDC). Public medical schools and private medical schools account for half of the proportions, and class sizes range from 400 students to 100 students. Dr. Abdul Majeed, who graduated from the Institute of Medical Sciences in Lahore, points out that Pakistan’s medical education faces three major problems. One is that most medical school teachers do not have any teaching qualifications. They are simply graduates of the same system and prefer teaching over clinical practice. Therefore, there are a large number of medical graduates in the country, and the lack of clinical practice ability is a medical concern. Another big problem is that professional examinations are rarely based on concepts, the examinations lack standardization, and there are doubts to check on the ability of doctors. Finally, the inadequacy of emphasis on research in medical education in Pakistan has resulted in doctors' knowledge level lagging far behind medical graduates from other countries.

IV.    Mental health system and health promotion

　　The 2017 report of WHO’s Mental Health Atlas showed that the country had only 4 large psychiatric hospitals, of which general hospitals had 344 inpatient care facilities and 654 psychiatric departments. The number of mental health beds was 2.1 per 100,000 population. The prevalence of mental illness among children in Pakistan is high, but it is still challenging to involve children and families in treatment. Only 343.34 patients per 100,000 people are treated.

　　The average number of medical treatments per patient is 9.31. 46% of outpatient facilities provide medical services in the community, and 1% have a mental health mobile team. In terms of early preventive measures, 1%-20% of patients have received one or more services in the past year. There are 624 community psychiatric inpatient wards across the country, providing 1.926 beds per 100,000 people. In community inpatient wards, only 1% of the beds are reserved for children and adolescents.

　　The hospital is integrated with mental health clinics and outreach programs related to primary care. In recent years, the number of beds in mental hospitals has decreased, and now more attention is paid to small units such as general hospitals, community institutions, and general health centers. In addition to mental health beds, the forensic inpatient department has 0.02 beds for patients with mental disorders, and 1,620 beds for other residential institutions, such as homes for patients with intellectual development disabilities (learning disabilities), inpatient detoxification institutions, and homes for the poor.

　　There are 3,729 mental health clinics nationwide, of which only 1% are for children and adolescents. For all patients treated in mental health clinics, 69% are women and 46% are children or adolescents. Among the patients treated in the outpatient clinic, the neurological, stress-related and somatizing diseases (33%) and depression (30%) are diagnosed. 33% of mental health clinics have at least one treatment antipsychotic (antipsychotics, antidepressants, stabilizers, anxiolytics and antiepileptics at or near emotional facilities). There are no day care facilities in the country. The mental health budget accounts for 0.4% of total health care expenditures.

　　Pakistan BNPAK (BasicNeeds Pakistan) is an independent international program, it is a global mental health organization dedicated to improving the lives of patients with mental illness and/or epilepsy. The country is a member of the BasicNeeds International Federation. It has been working in Pakistan since 2013 and is one of the few non-governmental organizations in the region. These organizations use a comprehensive community approach to address the needs of people with mental health problems. The plan was launched to implement and adjust the five-step approach to mental health and development in Pakistan, including capacity building, community mental health, livelihoods, research, and cooperation.

V.       Major issues, challenge, and opportunities

　　In the past few decades, drug abuse in Pakistan has been multiplied. Most illegal drugs come from neighboring Afghanistan. The United Nations estimates that 8.9 million people in the country are the drug abusers. Marijuana is the most commonly used drug. The rate of injection drug abuse in Pakistan has also increased significantly, and raising the concerns about HIV epidemic. Although the increasing problem is shocking, the government seems to pay no concern to this issue. The country has no activities and measures to deal with the drug smuggling and addicts, and the supply of drugs is almost unlimited. The Anti-Narcotics Force is a government agency responsible for combating the smuggling and use in Pakistan.

　　Due to the rapid increase in violence in Pakistan's society, common mental health problems have been found in both rural and urban populations. According to scholars' inferences, it is positively related to socioeconomic dilemmas, interpersonal relationship problems, and lack of social support. There are a lot of mental diseases, the depression and anxiety disorders are the highest, while many cases like schizophrenia, mental and physical disorders, obsessive-compulsive disorder and post-traumatic stress disorder can also be seen in the country

　　In addition, there are serious substance abuse and drug addiction problems. According to the 2013 United Nations Office on Drugs and Crime (UNODC) data, Pakistan has the largest number of substance users in the world, and the increasing number of them in the urban area has caused a public health dilemma.

VI.    Potential exchange issues

　　Due to the influence of the socio-economic environment and historical context, more schizophrenia with other mental disorders such as physical and mental disorders, depression and anxiety, obsessive-compulsive disorder and post-traumatic stress disorder which have been emerged in Pakistan for a long time, and meanwhile, there is also a very high rate of drug addiction patients. Therefore, treatment programs for the aforementioned common mental illnesses, substance abuse and drug addiction are all the topics that can be exchanged in the future.