Mental health care in Nepal: current situation and challenges for development of a district mental health care plan

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Abstract

Background

Globally mental health problems are a serious public health concern. Currently four out of five people with severe mental illness in Low and Middle Income Countries (LMIC) receive no effective treatment. There is an urgent need to address this enormous treatment gap. Changing the focus of specialist mental health workers (psychiatrists and psychologists) from only service delivery to also designing and managing mental health services; building clinical capacity of the primary health care (PHC) workers, and providing supervision and quality assurance of mental health services may help in scaling up mental health services in LMICs. Little is known however, about the mental health policy and services context for these strategies in fragile-state settings, such as Nepal.

Method

A standard situation analysis tool was developed by the PRogramme for Improving Mental health carE (PRIME) consortium to systematically analyze and describe the current gaps in mental health care in Nepal, in order to inform the development of a district level mental health care plan (MHCP). It comprised six sections; general information (e.g. population, socio-economic conditions); mental health policies and plans; mental health treatment coverage; district health services; and community services. Data was obtained from secondary sources, including scientific publications, reports, project documents and hospital records.

Results

Mental health policy exists in Nepal, having been adopted in 1997, but implementation of the policy framework has yet to begin. In common with other LMICs, the budget allocated for mental health is minimal. Mental health services are concentrated in the big cities, with 0.22 psychiatrists and 0.06 psychologists per 100,000 population. The key challenges experienced in developing a district level MHCP included, overburdened health workers, lack of psychotropic medicines in the PHC, lack of mental health supervision in the existing system, and lack of a coordinating body in the Ministry of Health and Population (MoHP). Strategies to overcome these challenges included involvement of MoHP in the process, especially by providing psychotropic medicines and appointing a senior level officer to facilitate project activities, and collaboration with National Health Training Centers (NHTC) in training programs.

Conclusions

This study describes many challenges facing mental health care in Nepal. Most of these challenges are not new, yet this study contributes to our understanding of these difficulties by outlining the national and district level factors that have a direct influence on the development of a district level mental health care plan.

Electronic supplementary material

The online version of this article (doi:10.1186/s13031-014-0030-5) contains supplementary material, which is available to authorized users.

Related collections

Most cited references 49

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Poverty and common mental disorders in low and middle income countries: A systematic review.

Crick Lund, Alison Breen, Alan J Flisher … (2010)

In spite of high levels of poverty in low and middle income countries (LMIC), and the high burden posed by common mental disorders (CMD), it is only in the last two decades that research has emerged that empirically addresses the relationship between poverty and CMD in these countries. We conducted a systematic review of the epidemiological literature in LMIC, with the aim of examining this relationship. Of 115 studies that were reviewed, most reported positive associations between a range of poverty indicators and CMD. In community-based studies, 73% and 79% of studies reported positive associations between a variety of poverty measures and CMD, 19% and 15% reported null associations and 8% and 6% reported negative associations, using bivariate and multivariate analyses respectively. However, closer examination of specific poverty dimensions revealed a complex picture, in which there was substantial variation between these dimensions. While variables such as education, food insecurity, housing, social class, socio-economic status and financial stress exhibit a relatively consistent and strong association with CMD, others such as income, employment and particularly consumption are more equivocal. There are several measurement and population factors that may explain variation in the strength of the relationship between poverty and CMD. By presenting a systematic review of the literature, this paper attempts to shift the debate from questions about whether poverty is associated with CMD in LMIC, to questions about which particular dimensions of poverty carry the strongest (or weakest) association. The relatively consistent association between CMD and a variety of poverty dimensions in LMIC serves to strengthen the case for the inclusion of mental health on the agenda of development agencies and in international targets such as the millenium development goals. Copyright 2010 Elsevier Ltd. All rights reserved.

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Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries

Charlotte Hanlon, Nagendra P. Luitel, Tasneem Kathree … (2014)

Background Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

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WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care.

Graham Thornicroft, Atalay Alem, Renato Antunes Dos Santos … (2010)

This paper provides guidance on the steps, obstacles and mistakes to avoid in the implementation of community mental health care. The document is intended to be of practical use and interest to psychiatrists worldwide regarding the development of community mental health care for adults with mental illness. The main recommendations are presented in relation to: the need for coordinated policies, plans and programmes, the requirement to scale up services for whole populations, the importance of promoting community awareness about mental illness to increase levels of help-seeking, the need to establish effective financial and budgetary provisions to directly support services provided in the community. The paper concludes by setting out a series of lessons learned from the accumulated practice of community mental health care to date worldwide, with a particular focus on the social and governmental measures that are required at the national level, the key steps to take in the organization of the local mental health system, lessons learned by professionals and practitioners, and how to most effectively harness the experience of users, families, and other advocates.

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Author and article information

Contributors

Nagendra P Luitel: luitelnp@gmail.com

Mark JD Jordans: mark.jordans@hntpo.org

Anup Adhikari: adhikari.anup82@gmail.com

Nawaraj Upadhaya: navarajtpo@gmail.com

Charlotte Hanlon: charlotte.hanlon@kcl.ac.uk

Crick Lund: crick.lund@uct.ac.za

Ivan H Komproe: ivan.komproe@hntpo.org

Journal

Journal ID (nlm-ta): Confl Health

Journal ID (iso-abbrev): Confl Health

Title: Conflict and Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1752-1505

Publication date (Electronic): 6 February 2015

Publication date PMC-release: 6 February 2015

Publication date Collection: 2015

Volume: 9

Electronic Location Identifier: 3

Affiliations

[ ]Research Department, Transcultural Psychosocial Organization (TPO), Kathmandu, Nepal

[ ]Research and Development Department, HealthNet TPO, Lizzy Ansinghstraat 163, 1073 RG, Amsterdam, The Netherlands

[ ]Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Box P029 De Crespigny Park, London, SE5 8AF UK

[ ]Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

[ ]Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

[ ]Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands

Article

Publisher ID: 30

DOI: 10.1186/s13031-014-0030-5

PMC ID: 4331482

PubMed ID: 25694792

SO-VID: a941f951-60b5-42bb-9585-3df355603b26

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 14 May 2014

Date accepted : 26 December 2014

Custom metadata

ScienceOpen disciplines: Health & Social care

Keywords: mental health,situation analysis,integration of mental health into phc,mental health care plan,nepal

Data availability:

ScienceOpen disciplines: Health & Social care

Keywords: mental health, situation analysis, integration of mental health into phc, mental health care plan, nepal