Primary

Health Care
Mental Health in Pakistan

Submitted by: Qaiser Zaman

Submitted to: Brig Prof Iqbal Ahmad Khan

Mental Health
Mental health is a state being in which the individual realizes his or her
state of emotional and psychological well-being in which an individual is able to use his or her cognitive
and emotional capabilities, function in society, and meet the ordinary demands of everyday life.
Mental health is the successful performance of mental function, resulting in productive activities,
fulfilling relationships with other people, and providing the ability to adapt to change and cope
with adversity.

It is a level of psychological well-being, or an absence of a mental illness. It is the "psychological

state of someone who is functioning at a satisfactory level of emotional and behavioral
adjustment". From the perspective of positive psychology or holism, mental health may include an
individual's ability to enjoy life, and create a balance between life activities and efforts to
achieve psychological resilience.
According to the World Health Organization, mental health includes "subjective well-being,
perceived self-efficacy, autonomy, competence, inter-generational dependence, and self-
actualization of one's intellectual and emotional potential, among others." The WHO further states
that the well-being of an individual is encompassed in the realization of their abilities, coping with
normal stresses of life, productive work and contribution to their community.

Mental Health in Pakistan

Mental health in Pakistan has remained a subject of debate since the last few years. The incidence
and prevalence have both increased tremendously in the background of growing insecurity,
terrorism, economical problems, political uncertainty, unemployment and disruption of the social
fabric. Sinking below poverty line by almost 39% of the individuals is an alarming factor worth
noting. Many people are now presenting to psychiatrists probably because of the growing
awareness through the good work of media. Though there are many things which can be done to
improve the mental health of the people in the areas of social environment, economic improvement
and political harmony etc. but the important subject for debate is that, how far we are in the areas
of education, service and research related to mental health having direct impact on the patient
population. From 1947 to 2005, almost 58 years have passed since the independence of the country
and many countries with this age have done wonders in overall upkeep of health care and specially
the mental health.
Mental Health Services
There has been an almost 100 per cent rise in the incidence of mental disorders, particularly stress
and depression, in the country over the past 10 years, mainly due to the issues of personal
insecurity, poverty, lack of education, rising inflation and ramshackle power supply,apart from
genetic reasons, rising targeted killings, extortion, bodies found stuffed in gunny bags and frequent
power breakdowns during the last couple of years had aggravated significantly the stress level in
Pakistani society.

In Pakistan, there were four mental health hospitals in Hyderabad, Lahore, Peshawar and
Mansehra with a total capacity of 3,000 beds, while small psychiatric units were attached to
teaching hospitals and private psychiatric hospitals had a capacity of about 4,000 beds for patients
reporting with mental disorders, he said. He lamented that there were only 419 psychiatrists in the
country, concentrated mostly in urban areas, while there were no trained psychiatric nurses and
community mental health workers. There had been a longstanding demand for a meaningful
investment in the mental health sector, development of workforce and infrastructure.

A national mental health authority exists which provides advice to the government on mental
health policies and legislation. The mental health authority also is involved in service planning,
service management and co-ordination and in monitoring and quality 10 assessment of mental
health services. Mental health services are not organized in terms of catchment/service areas.
There are 3729 outpatient mental health facilities available in the country, of which 1% is for
children and adolescents only. These facilities treat 343.34 users per 100,000 general population.
Of all users treated in mental health outpatient facilities, 69% are female and 46% are children or
adolescents. The users treated in outpatient facilities are primarily diagnosed with neurotic, stress
related and somatoform disorders (33%) and mood disorders (30%). The average number of
contacts per user is 9.31. Forty-six percent of outpatient facilities provide follow-up care in the
community, while 1% has mental health mobile teams. In terms of available interventions, 1- 20%
of users have received one or more psychosocial interventions in the past year. 33% of mental
health outpatient facilities had at last one psychotropic medicine of each therapeutic class (anti-
psychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines) available in the
facility or a near-by pharmacy all year round. Day treatment facilities are not available in the
country.

Public Education and Links with Other Sectors

There is a coordinating body to oversee public education and awareness campaigns on mental
health and mental disorders. Government agencies (e.g., Ministry of Health or Department of
mental health services); NGOs; professional associations, private trusts; and foundations,
International agencies have promoted public education and awareness campaigns in the last five
years. These campaigns have targeted the following groups: The general population; children,
adolescents, women, trauma survivors, ethnic groups, and other vulnerable or minority groups. In
addition, there have been public education and awareness campaigns targeting professional groups
including health care providers (conventional; modern; allopathic); complimentary/ alternative/
traditional sector; teachers; social services staff; and other professional groups linked to the health
sector.
The following legislative and financial provisions exist to protect and provide support for users:
(1) provisions concerning a legal obligation for employers to hire a certain percentage of
employees that are disabled,
(2) Provisions concerning protection from discrimination (dismissal, lower wages) solely on
account of mental disorder,
(3) Provisions concerning priority in state housing and in subsidized housing schemes for people
with severe mental disorders, and
(4) Provisions concerning protection from discrimination in allocation of housing for people with
severe mental disorders. All of these provisions exist but are not enforced. Government agencies
(e.g., Ministry of Health or Department of mental health services); NGOs; professional
associations, private trusts; and foundations, International agencies have promoted public
education and awareness campaigns in the last five years.

Policy and Legislative Framework

1960-1980
Mental Health organizations, spearheaded by PAMH, began the demand for the Lunacy Act 1912
to be repealed. Dedicated advocacy movements and resolutions were undertaken. The need for a
humane Mental Health Act several draft documents were sent to the Government

1998-2001
After a several year lull the advocacy drive took a turn towards improvement. PAMH led various
Mental Health organizations to push for a change. Several legal seminars and discussions were
organized to highlight the controversial clauses and provide alternatives to the government.

2001
The Government was finally convinced that there were no financial implications to repeal Lunacy
Act 1912. An ordinance was drafted with great haste and presented at the biennial conference of
Pakistan Psychiatric Society in Islamabad, 2001. This proposal contained several contradictions
and was ordered to be rehashed within two weeks by then president, General Musharaf. Federal
Law Minister Barrister Shahida Jameel produced a revised document which was then passed
as Mental Health Ordinance 2001.
2001-2007
Pakistan Association for Mental Health began careful scrutiny of the Ordinance, and held series of
seminars, meetings, consultations with jurists, psychiatrists, psychologists and users. Minimum
changes were proposed which could make it workable in prevalent conditions. In the meantime all
the relevant authorities were repeatedly reminded for its implementation.

Pakistan's mental health policy was last revised in 2003 and includes the following
components:
(1) Developing community mental health services,
(2) Downsizing large mental hospitals,
(3) Developing a mental health component in primary health care,
(4) Human resources,
(5) Involvement of users and families,
(6) Advocacy and promotion,
(7) Human rights protection of users,
(8) Equity of access to mental health services across different groups,
(9) Financing
(10) Monitoring system.
In addition, a list of essential medicines is present. These medicines include Antipsychotics,
Antidepressants, Mood stabilizers and Antiepileptic drugs. The last revision of the mental health
plans was in 2003. This plan contains the same components as the mental health policy but also
includes reforming mental hospitals to provide more comprehensive care, and quality
improvement. In addition, a budget, a timeframe and specific goals are identified in last mental
health plan.

A disaster/emergency preparedness plan for mental health is present and was last
revised in 2006.
(1) Access to mental health care including access to the least restrictive care,
(2) Rights of mental health service consumers,
(3) Family members, and other care givers,
(4) Competency, capacity, and guardianship issues for people with mental illness,
(5) Voluntary and involuntary treatment,
(6) Accreditation of professionals and facilities,
(7) Law enforcement and other judicial system issues for people with mental illness,
(8) Mechanisms to oversee involuntary admission and treatment practices, and
(9) Mechanisms to implement the provisions of mental health legislation.

2007
As the ordinance was not implemented for more than 6 years, in 2007 PAMH decided to file
a petition in Sindh High Court. Federal Minister of Health was summoned and ordered to
reconstitute Federal Mental Health Authority (whose term had expired several years ago) and take
measures to implement MHO 2001.

2008
The Federal Ministry of Health reconstituted Federal Mental Health Authority on 28th July 2009
and called a meeting in Islamabad, where decision was taken and subcommittees constituted to
frame rules and regulation and expedite formation of Board of Visitors in provinces. Budgetary
provision suggested was deferred. As a result of 18th Amendment on 8th April, 2010 the Federal
Mental Authority was dissolved. MHO 2001 was then sent to each province to frame its own
Mental Health Act.

2011
Our efforts continue towards incorporating the advice of leading jurist from time to time from
2001 onwards. With the cooperation and collaboration of Human Rights Commission of Pakistan
(HRCP) holding this consultation to finalize a draft to be submitted to ministry of health Sindh
which will forward it to the Sindh Assembly.
The minimum but outdated clauses where replace with more practical clauses prepared with the
help of experts from lawyers community and from England (Dr Muzaffar Hussain and Dr Tony)
accepted PAMH proposal and Dr Mandhro got it passed from Sindh Assembly. During the brief
Caretaker regime in 2013, PAMH saw the perfect opportunity and with the hlp of Mr. Mahmood
Mandviwala (Law Minister) passed the Ordinance into an Act through the Sindh Assembly.
The Sindh Mental Health Act 2013 became the first Act in Sindh after 100 years (replacing Luncy
Act 1912).

2015
One clause remained untouched, and unchanged, which to the PAMH was of utmost importance.
Relevant to the Blasphemy Law, PAMH refused to approve the Act without this provision. After
much to and fro, in February 2015, this monumental victory was achieved