|Year : 2021 | Volume
| Issue : 1 | Page : 8-13
Critique of the Mental Health System in Nepal, COVID-19 Response, and Recommendations
Carly Cox1, Zara Sami1, Mona Thapa2
1 Milken Institute of Public Health, George Washington University, Washington, DC, USA
2 Yale University, New Haven, CT 06520, USA
|Date of Submission||22-Sep-2020|
|Date of Acceptance||03-Dec-2020|
|Date of Web Publication||29-Apr-2021|
Dr. Mona Thapa
Yale University, New Haven, CT 06520
Source of Support: None, Conflict of Interest: None
Nepal has a multitiered health system involving the Ministry of Health, nongovernmental organizations, private for profit, and faith-based organizations. There are national, district, and community-level health centers and health workers that come together to deliver services and input information into both the community and national level health information systems. In terms of mental health, there is a very small portion of the budget allocated to mental health and very few mental health interventions and programs. The system has strengths including that the service delivery is put together in an effective manner and there is some mental health integration in primary care and in the health information system. However, there are weaknesses including that there needs to be an increase in the number of health workers and the training given to the workforce to further integrate mental health and there also needs to be more attention brought to mental health overall. Nepal's COVID-19 response highlighted weaknesses within its health system, especially in the context of its essential medicine products. The COVID-19 response from Nepal was especially hindered by a shortage of medical supplies, personal protective equipment, medications, and coronavirus tests.
Keywords: COVID-19, health, mental, Nepal, World Health Organization
|How to cite this article:|
Cox C, Sami Z, Thapa M. Critique of the Mental Health System in Nepal, COVID-19 Response, and Recommendations. World Soc Psychiatry 2021;3:8-13
| Introduction|| |
The health system and mental health system of Nepal are discussed in this article, along with the response to the COVID-19 pandemic. A literature search was done and both articles from journals and papers along with peer-reviewed journals were used to collect the information for this article. The health systems were evaluated through use of the World Health Organization (WHO) framework to compare the system to the guidelines and standards. Nepal's response to the current coronavirus relating to quarantine, social distancing, testing, and contact tracing is also discussed. By using the WHO framework to evaluate Nepal's health system, we were able to pinpoint strengths and weaknesses within six core components of the health system. By recognizing these weaknesses within the health system, we were able to determine recommendations that we believe will strengthen Nepal's health system and improve health outcomes within the country.
| Country Overview|| |
Nepal is a landlocked country in the continent of Asia, with a population of 31 million people. Many of the highest mountains are in this region, including Mount Everest. Seventy-five percent of the country consists of mountains. The capital city of Nepal, Kathmandu, is located in the central region of the country.
The main religions practiced in Nepal are Hinduism and Buddhism. The percentage of people who practice Hinduism in 2011 was about 81.3%. Nepali is the primary language spoken in the country. A majority of 80.3% of the land is rural, while 19.7% of the land is urban. As of 2017, 30.2% of the population was under 15, while 30.5% of the population was between the ages of 15 and 29 years. These are the largest age groups. Under 20% of the population was in the 30–44 age range and only 1.4% of the population was over 75.
Noncommunicable diseases account for about 66% of deaths in Nepal as of 2016. About 30% of deaths are caused by cardiovascular disease. The top five causes of death in 2017 were heart disease, chronic obstructive pulmonary disease, diarrheal diseases, lower respiratory infections, and intracerebral hemorrhage. The fertility rate is 1.9 live births/min.
| Mental Health Burden|| |
The mental health burden in Nepal is very high, and Nepal is the country with the seventh highest suicide rate. Posttraumatic stress disorder was a major health issue in Nepal due to an earthquake that occurred in 2015. This earthquake had a significant impact which has been demonstrated by a study done in the past which showed that there was a higher prevalence of mental health disorders in the Dolakha and Bhaktapur districts, which were most affected by the earthquake. The prevalence of adults with a mental health disorder is about 13.2% and the risk of suicide among adults is 10.9%. In terms of mental health of children, about 11.2% of children in Nepal have a mental disorder.
People in Nepal value mental health greatly, and some see it as more important than physical health due to spiritual attachments of being of good mental health. People in rural areas believe that people who have mental illnesses are possessed by evil spirits and this increases stigma. A barrier to receiving mental health care from health professionals is that due to cultural beliefs, people are more likely to go to spiritual leaders for treatment rather than a facility. Negative associations to people who have mental illnesses make it difficult for people to seek care. Family members are usually the decision-makers for those who may have a mental health issue and due to the high stigma, they are unlikely to seek help for their family members.
| Leadership and Governance|| |
There is a mixed health delivery system in Nepal which involves the Ministry of Health (MOH), Nongovernmental Organizations (NGO), and faith-based organizations (FBO). Rural populations are the focus of the MOH. Urban populations are addressed through NGOs, FBOs, and private organizations. The MOH is also in charge of developing and governing the health policy of the country. In terms of government attention to mental health, the government of Nepal, which changes leadership frequently, does not prioritize mental health as only 1% of the health budget it allocated toward mental health funding. The increase in NGO attention to mental health and inclusion of mental health in policies have been listed as beneficial improvements. Barriers include a lack of strong leadership in terms of implementation of mental health policies and programs. The MoH also does not have a mental health unit and there is not an adequate amount of mental health policies or acts.
Leadership and governance is organized in Nepal at different levels, it is important to increase awareness of mental health issues and have the leadership prioritize mental health. It is apparent by the research that there is not enough money allocated to mental health and that the leadership is not doing much to increase outcomes. The public health system in Nepal does not have mental health awareness campaigns and it is vital to increase these campaigns so that both leaders and the population can understand the importance of mental health services in the country. The leadership also needs to implement the policies and integrate mental health into primary care along with within the MoH.
| Health System and Services|| |
In Nepal, there is a large amount of stigmatization surrounding mental illness and mental health care. This is reflected by Nepal's mental health system which is underfunded, under-resourced, and understaffed. With a population of nearly 29 million, Nepal has roughly 125 psychiatrists, which equates to 0.129 psychiatrists per 100,000 people. These psychiatrists primarily practice within urban areas, leaving rural communities with minimal trained psychiatric health care. There is a vast shortage of medical doctors in Nepal, with a patient–doctor ratio being 1:1724. Due to the substantial psychiatrist shortage in Nepal, mental health care is primarily provided by religious leaders/traditional healers or within the primary care sector.
Primary health care somewhat involves mental health due to the fact that about 2% of the training for doctors and nurses includes information about mental health. However, it has been reported that the majority of primary care providers feel that their mental health-care training was minimal, which has resulted in limited mental health treatment knowledge and a general discomfort regarding treating mental health disorders. Mental health assessment and treatment protocols are available in primary health clinics; however, limited provider knowledge and/or training may lead to inadequate treatment or misdiagnosis.
There are multiple levels of the health system. The central level involves the central hospital where the MOH may coordinate services along with primary, secondary and tertiary care. The next level of the health system is the regional level which includes zonal hospitals which also focus on primary, secondary, and tertiary care. District and primary health centers follow emergency, primary, and secondary care. One section of the community sector is the Village Development Committee (VDC), which includes health posts, auxiliary health workers (AHW), and auxiliary nurse midwives. The other part of the community sector is the ward which includes female community health volunteers (FCHV) and clinics. The FCHVs have multiple responsibilities; however, they do not have any mental health training.
In terms of mental health, the health services in Nepal are very limited. While there are private for-profit mental hospitals, there is only one government mental health hospital in the country. There are under twenty outpatient mental health centers, and while each hospital is equipped with a psychiatric unit, there are a limited number of beds available. Health centers that focus primarily on child and adolescent mental health in Nepal are in short supply. Children and adolescent mental health services are also lacking in Nepal. There is currently one child and adolescent psychiatric unit within the children's hospital. The health services are further outlined in [Table 1].
The Nepal public health system does not have any mental health awareness campaigns; however, NGOs have come up with interventions in the past. NGOs have created mental health awareness programs, but these are in specific and smaller populations due to the fact that they cannot be backed by the MoH. The MoH has created crisis centers throughout the country for people who may be facing gender-based violence and these centers involve some mental health care. After the earthquake in 2015, mental health awareness programs were put together to increase awareness due to the mental health issues that emerged from this natural disaster.
The service delivery of mental health care in Nepal can use some improvements, especially regarding reaching more of the population. In Nepal, we see the majority of psychiatrists and medical doctors in general practicing within urban areas. This results in rural areas experiencing a severe health-care provider shortage. This issue could be addressed by providing an incentive for psychiatrists or medical doctors who practice in a rural area within Nepal. The lack of mental health training primary care doctors receive also needs to be addressed. By restructuring medical training in Nepal to place a larger emphasis on mental health care, primary care physicians will have more knowledge, skills, and training to diagnose and treat mental health conditions. Integrating mental health care in primary care will increase mental health-care accessibility and decrease stigma. It will also decrease the amount of fragmentation that is currently an issue within the Nepal health-care system. By integrating care within a culture of total health, we are increasing the likelihood a patient will not fall through the cracks or their care will be mismanaged.
The health system in Nepal should also invest and focus on the prevention and promotion of mental health. There are currently no mental health prevention or promotion programs in Nepal. This must be made a priority. Not only is this a cost-effective solution in the long run, due to the fact it will decrease the need for treatment over time, but it will also help promote more successful mental health outcomes within Nepal's population.
It is also recommended that Nepal increases the amount of mental health hospitals. There are a limited number of mental health centers/hospitals and only one of those focuses primarily on child and adolescent mental health treatment. We recommend Nepal directs their mental health funding to support more mental health hospitals that primarily focus on children and adolescents. By treating and managing mental health issues at an early age, we are decreasing the likelihood that it will be exacerbated and require more complex treatment later in life.
| Health Workforce|| |
There are about over 54,000 health workers in Nepal in both the private and public sectors. There are about 0.17 doctors/1000 population and 0.50 nurses/1000 population in Nepal. Most of the doctors are in central hospitals. [Table 2] shows the amount of health workforce in each type of occupation (Nepal Health Sector Support Programme).
The health workforce in Nepal is lacking mental health specialists. The total number is around 0.59/100,000 population. There are about 0.129 psychiatrists/100,000 population and 0.0645 mental health doctors per 100,000 population. When it comes to mental health nurses, there are 0.274 total per 100,000 population. There are no occupational therapists or social workers. Urban areas have a higher concentration of mental health workforce members than in rural areas.
In terms of health workforce recommendations, there needs to be an increase in the number of doctors and nurses in the health workforce, as there are very few in relation to the WHO standards, according to the literature. Mental health needs to be further integrated into the education of all of the health workforce workers. There are also too few mental health specialists in the country and this needs to change.
It is also extremely important that community health-care providers (VDC, AHW, and FCHV) be adequately trained in mental health prevention and identification. Training community health workers and faith healers in identifying mental illnesses would be beneficial to improving the health workforce and would also be cost-effective. In some areas of Nepal, community health-care providers deliver the majority of health care; therefore, it is essential they be able to recognize mental health distress or illness and be able to refer patients to a provider who can assist in their treatment and recovery.
| Health Information Systems|| |
The community health management information system (cHMIS) in Nepal is the system that focuses on the performance of community-level health systems. AHWs and ANMs collect data from FCHVs every month. The information then goes to the health management information system (HMIS) which takes the data from district hospitals to central levels. The forms are integrated so that they are easy to fill out by volunteers and health workers who are less skilled. About 97% of FCHVs have used cHMIS and the system is paper based.
Mental health indicators are integrated into the overall health information system in Nepal. These indicators are not used at the community level because the FCHVs are not trained in mental health and do not have the skills to include the mental health indicators. Primary health care and district-level health-care doctors and medical professionals keep records. These data are recorded on the national HMIS through a web portal. About 47 mental health issues were reported by the Department of Health Services).
Despite having both community and national systems, there needs to be an increase in mental health education among the people who are collecting data at a community level because mental health indicators are not included in the cHMIS. Training for FCHVs should be increased to integrate mental health indicators at the community level, or the data should be collected by a workforce member that may be able to understand these indicators better.
| Essential Medical Products|| |
According to a study that was done in Nepal, private centers had a higher availability of medications than public centers. Private health centers had an availability of about 78%, while public centers had an availability of about 60%. There was not much availability of oxygen in either type of center. Availability was lacking in centers for people at a lower economic status. Psychotropic drugs are readily available in mental health centers in Nepal; however, Nepal does experience a pharmaceutical shortage which stems from various factors.
It is essential Nepal addresses their medication shortage issue. Antivirals, antifungals, mental health drugs, and asthma medications are the most vulnerable pharmaceuticals to becoming scarce in Nepal. Not having access to these medications may lead to disastrous physical and mental health consequences. Due to the lack of health-care funding by the government, there is not a substantial amount of financing invested for procuring pharmaceutical drugs. This can be addressed by Nepal increasing health financing and prioritizing this spending toward the multiple issues that exacerbate Nepal's medication shortage problem. Other issues that contribute to the medication shortage in Nepal are manufacturing issues, not enough raw materials, natural disasters, supply and demand issues, and regulatory problems. While increased funding cannot solve all these factors, it certainly could help minimize them.
In 2009, the Nepal government determined that 40 medications were to be made available and to be given free of charge in government medical centers. In 2014, this list was expanded to include 30 more medications. While this was a step in the right direction, this list of medications could use a few improvements. One improvement would be to expand the medication list to be more aligned with Nepal's current disease burden. In recent years, the most common causes of death in Nepal have moved from communicable to noncommunicable diseases; however, the medication list fails to reflect this change as effectively as it could. This medication list also fails to incorporate a variety of psychotropic drugs that have the capacity to help treat mental health disorders, which in recent years have been a major contributor to Nepal's burden of disease.
| Health Financing System|| |
There is a significant amount of hardship in terms of health expenditure burden in Nepal. About 3 million people had a burden of health expenditure larger than 10% of their expenses. There are some policy initiatives for universal health coverage. Essential medications are affordable despite a lack of availability.
As mentioned earlier, there is not much funding in terms of mental health in Nepal. There is very low government spending on health care and it has not changed in the past years. Out-of-pocket expenditures have also not changed in the past few years. Over 60% of health-care financing costs in Nepal are out of pocket. This includes finances related to medications, doctor appointments, testing, and stays in hospitals. These out-of-pocket costs are the reason for the increase in health expenditure in the past decade as a share of the gross domestic product in Nepal.
Nepal must make mental health care a priority. This should be reflected by their mental health funding allotted by the government. Health financing in Nepal needs to be addressed and improved. There are a very small number of funds for health and especially for mental health in Nepal. The number has not grown in the past decade and this is a major issue. Nepal's government needs to address its lack of health financing sooner rather than later as this issue is extremely vital during the coronavirus pandemic. In terms of mental health, it will be important especially due to this pandemic to increase funding and services.
Health care within Nepal is still not universal and out-of-pocket spending is substantial. A universal health-care system is recommended that assists in funding both physical and mental health care. This will reduce out-of-pocket medical costs for the citizens of Nepal and will help ensure that physical and mental health care is not neglected due to financial reasons. This will also encourage citizens of Nepal to utilize preventative physical and mental health services.
| Mental Health and COVID-19|| |
As of April 14, Nepal had reported 16 cases of coronavirus in the country. On this date, the nationwide lockdown was extended to April 27 after neighboring country India extended their lockdown until mid-May. Lockdown in Nepal included stopping public transportation and closing everything other than essential businesses including hospitals, grocery stores, and law enforcement. People in Nepal have also been told to stay indoors during this pandemic. The government was somewhat slow in limiting international travel which could have led to the slight increase in cases in the country. The government was also not very involved in enforcing quarantining, which probably led to a further increase in cases. A lack of resources also made it difficult to assist people who may have the virus. It was difficult for testing to occur due to the lack of staff and location of testing facilities being concentrated in one city. Only about 35 people were able to be tested on a daily basis in April due to a lack of resources. Usually, Nepal is able to gain resources and assistance from other countries, but due to the global burden that is occurring because of this virus, it is difficult for other countries to send out resources and help. The United States and Germany had assisted; however, there was a lot that Nepal still needed in terms of coronavirus tests, protective equipment, and medication.
As of June 10, 2020, there were 279 daily new cases of the coronavirus in Nepal, and the overall number of cases had increased to 4364 cases. By July 7, 2020, the cases have increased substantially, with Nepal now having an overall number of 16,166 confirmed cases. The regions that border India have been identified as hotspots for the virus. According to the prime minister, the reasoning for the increase in cases is due to the fact that people are returning from India; however, recently, transmission throughout the community has also accounted for a significant rise in cases. The government is now addressing this increase in cases through increasing the number of tests administered to 5000 a day and increasing the health workforce for both contact tracing and testing. There are also over three thousand quarantine centers in Nepal. The conditions in these quarantine facilities have been heavily criticized and protested. Overcrowding, failure to provide basic necessities, and safety concerns have all been issues within governmental quarantine centers and the mismanagement of these facilities has been regarded as a governmental failure in Nepal's response to the COVID-19 pandemic. Lack of money, essential medical supplies, and health workforce have all been deemed contributing factors to why these governmental quarantine centers have been heavily scrutinized by public health and human rights experts.
As of July 7, 2020, COVID-19 has been the contributing factor to 35 deaths in Nepal. The fatality rate is significantly higher among men than women. Experts have predicted that this gender disparity could be related to the high amount of gender inequality that is prevalent within Nepal. It has been reported by the Nepal Labor Force Survey that Nepalese women are less represented within the workforce. Recent data has shown that for every 100 men who are employed in Nepal, there are only 59 women employed. This lack of representation within the Nepalese workforce could have been a protective factor for women, leading them to be less likely to be exposed to COVID-19 and could account for why the COVID-19 fatality and infection rate is so low among Nepalese women. Younger men in Nepal tend to be infected by COVID-19 at higher rates than any other age or sex within the population. Of the overall cases of COVID-19 in Nepal, 86% of these cases were between the ages of 15 and 54 years and male.
The COVID-19 pandemic has not only had a significant impact on physical health in Nepal but also mental health. On March 24, 2020, the Nepali government enacted a full lockdown which resulted in restrictions regarding travel and the closure of nonessential businesses and schools. This lockdown was implemented to originally only last for 12 days; however, due to a continued surge in cases, it has been extended multiple times. The full lockdown implemented by the Nepali government and the fear and uncertainty triggered by the COVID-19 pandemic had a negative impact on the mental health of the population. It could have also been responsible for exacerbating prior mental health issues, which could have been a contributing factor regarding the rise in suicides that occurred over the first 75 days that the lockdown was implemented. It is estimated that over 1200 individuals in Nepal committed suicide during the first 75 days of lockdown. Experts have predicted that negative mental health repercussions due to the COVID-19 pandemic will continue, even after the pandemic is over.
| Strengths|| |
There are multiple strengths when it comes to the mental health system in Nepal. The MOH, NGOs, and FBOs are an effective set of organizations that address health in Nepal and the specific focuses of rural and urban populations are vital in making sure that needs of the entire population are met. Mental health is involved in some of the physician and nurse training, which is a strength. The multitiered health system is set up in an effective way, and the different types of health service workers lead to an effective way to address health issues at all levels of the country. The creation of crisis centers that have some mental health aspects is also a step in the right direction for the country. Another strength is that Nepal has both health information system and community health information system and that data are collected at both levels and then put together. There are also mental health indicators integrated into the national health information system. There are essential medical products and psychotropic drugs available in Nepal, which allows health facilities to properly address health issues.
| Weaknesses|| |
There are multiple weaknesses in Nepal's health system that need to be addressed. First, the attention to mental health is very minimal and the government does not seem to prioritize it. This is very harmful to the significant number of people in the population of the country that need mental health services. Although there is some level of training in terms of mental health involved in primary care training, the percentage is very low. There are very few mental health facilities in the country. The national public health system is severely lacking in mental health awareness campaigns and mental health programs. The health workforce is also too small, which impacts the entirety of the health system and is having an impact on the present-day pandemic, as people are unable to be tested for COVID-19 due to lack of resources and staff. The number of doctors and nurses is significantly lower than the WHO standards. Health information systems at the community level need to be improved due to the fact that mental health is not integrated at the community level. There is a lack of education of FCHVs when it comes to mental health and these are the workers who are collecting data for the cHMIS. Most of the financing for health is out of pocket for people who are seeking services and there is very low government spending on mental health to assist people in seeking care. This is a major weakness because the inability to access care is the main barrier in people attaining the mental health support that they need.
We would like to acknowledge the WHO for the use of their framework to evaluate our health systems. We would also like to acknowledge Professor Eliot Sorel for his instruction and wisdom. Finally , we would like to acknowledge our classmates who supported and encouraged us throughout this learning opportunity.
Financial support and sponsorship
Dr. Eliot Sorel.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]