EMRO Technical Publications Series
44
Mental health atlas 2014 Resources for mental health in the Eastern Mediterranean Region
EMRO Technical Publications Series
44
Mental health atlas 2014 Resources for mental health in the Eastern Mediterranean Region
WHO Library Cataloguing in Publication Data World Health Organization. Regional Office for the Eastern Mediterranean Mental health atlas 2014: resources for mental health in the Eastern Mediterranean Region / World Health Organization. Regional Office for the Eastern Mediterranean p. .- (EMRO Technical Publications Series; 44) ISBN: 978-92-9022-117-3 ISBN: 978-92-9022-118-0 (online) ISSN: 1020-0428 1. Mental Health Services - statistics & numerical data 2. Health Policy 3. Health Resources - statistics & numerical data 4. Health Care Rationing I. Title II. Regional Office for the Eastern Mediterranean III. Series (NLM Classification: WM 16)
© World Health Organization 2016 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. Layout by Punto Grafico. Printing by WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.
Contents Executive summary....................................................................................... 7 Introduction.................................................................................................... 7 Methods........................................................................................................... 9 Results........................................................................................................... 10 1. Mental health policy............................................................................................................................ 10 2. Mental health legislation..................................................................................................................... 13 3. Stakeholder involvement.................................................................................................................... 17 4. Government mental health spending.............................................................................................. 18 5. Mental health workforce.................................................................................................................... 21 6. Mental health training in primary care............................................................................................ 24 7. Service availability................................................................................................................................ 26 8. Service coverage for severe mental disorders.............................................................................. 29 9. Inpatient care........................................................................................................................................ 30 10. Continuity of care after discharge................................................................................................... 31 11. Social support....................................................................................................................................... 32 12. Mental health promotion and prevention...................................................................................... 32 13. Suicide prevention............................................................................................................................... 33 14. Core mental health indicator set..................................................................................................... 34
Discussion..................................................................................................... 35 Baseline comparison with the targets of the Comprehensive Mental Health Action Plan 2015–20...................................................................................................... 37
Executive summary
Executive summary The first assessment of available mental health resources in WHO Member States was carried out in 2001.1 Updates were published for 2005 and 2011.2,3 The Mental health atlas 2014 provides up-to-date information on the availability of mental health services and resources across the Eastern Mediterranean Region. This information was obtained via a questionnaire sent to designated focal points in each WHO Member State. Findings relating to key indicators can be used as a baseline against which to measure progress towards meeting the goals of the Comprehensive Mental Health Action Plan.4 Comparisons have also been made with the rest of the world and earlier mental health atlas reports. The latest key findings are presented in the Box below. Key findings
Introduction The WHO Atlas of mental health resources was first produced in 2001 and was updated in 2005 and 2011. It is an important resource on global information on mental health and a tool for developing and planning mental health services. The Comprehensive Mental Health Action Plan 2013–2020 was adopted by the 66th World Health Assembly in May 2013. The action plan sets out goals and objectives to be achieved by 2020. In order to monitor progress in achieving these targets and to monitor other critical aspects of mental health system development, a set of core mental health indicators was developed (see Table 1). The core mental health indicators for the action plan were incorporated into the Atlas
Regional reporting on core mental health indicators • All 22 countries of the Region at least partially completed the atlas questionnaire, although many countries did not fully complete the sections on financing, workforce, service use and suicide. Mental health governance • 55% of countries of the Region have updated their mental health policies or plans in the past 5 years, but only 32% of countries of the Region have mental health policies that are fully compliant with international human rights instruments. 73% of countries of the Region have mental health legislation, but only 27% have mental health legislation that is fully compliant with international human rights instruments. Implementation of mental health legislation is weak. Persons with mental disorders and family members are rarely involved in the formulation and implementation of mental health policies, laws and services. Financial and human resources for mental health • Levels of public expenditures on mental health are not known for most countries of the Region, suggesting that specific budgets may not be set aside for mental health services. Spending is very low (less than US$ 2, per capita), and the majority of funding goes to inpatient care, especially mental hospitals. • The median number of mental health workers in the countries of the Region is half that reported in the rest of the world, and there is extreme variation with greater density of mental health workers in health system group 1 countries. Mental health service availability and uptake • The median number of mental health beds per 100 000 population ranges from 1.7 in health system group 3 countries, through 6.4 in group 2 countries, up to 11.3 in group 1 countries. This compares with over 50 in high-income countries in the rest of the world; median rates of day care and outpatient facilities indicate they are relatively underdeveloped compared with the rest of the world. Mental health promotion and prevention • 41% of countries of the Region have at least two functioning mental health promotion and prevention programmes, a similar percentage to the rest of the world. Only 14% of countries of the Region have developed national suicide prevention strategies. Mental health information • 52% of countries of the Region regularly compile mental health–specific data covering at least the public sector. Vital reporting systems are poorly developed, and there are issues of underreporting of suicide. Less than 25% of countries were able to report on the number of suicides.
Atlas: mental health resources in the world 2001. Geneva: WHO; 2001. Mental health atlas 2005. Geneva: WHO; 2005. 3 Mental health atlas 2011. Geneva: WHO; 2011. 4 Mental health action plan 2013–2020. Geneva: WHO; 2013. 1 2
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Mental health atlas 2014
2014. Between 2014 and 2020, a mental health atlas survey will be carried out every 2 years so that progress towards meeting the targets of the Action Plan can be monitored. The WHO Regional Office for the Eastern Mediterranean has developed a framework for implementation of the action plan. The framework incorporated intermediate indicators to monitor progress towards the global goals and objectives. It is planned that these intermediate indicators will be
incorporated into the Mental health atlas in the Eastern Mediterranean until 2020. The Comprehensive Mental Health Action Plan 2013–2020 contains six indicators for assessing progress towards agreed objectives and targets (see Table 1). The WHO secretariat was requested to identify additional mental health indicators for Member States to report on (see Table 1, Service development indicators). Together, these form the core set of mental health indicators. The final set of
Table 1. Core mental health indicators, by action plan objective and target Action plan objectives Objective 1. To strengthen effective leadership and governance for mental health Action plan targets Target 1.1. 80% of countries will have developed or updated their policies or plans for mental health in line with international and regional human rights instruments (by 2020) Target 1.2. 50% of countries will have developed or updated their law for mental health in line with international and regional human rights instruments (by 2020) Objective 2. To provide comprehensive, integrated and responsive mental health and social care services in communitybased settings Target 2. Service coverage for severe mental disorders will have increased by 20% (by 2020) Action plan indicators Existence of a national policy/ plan for mental health that is in line with international and regional human rights instruments Existence of a national law covering mental health that is in line with international and regional human rights instruments Number and proportion of persons with a severe mental disorder who received mental health care in the past year Service development indicators Financial resources. Government health expenditure on mental health Human resources. Number of mental health workers Capacity-building. Number and proportion of primary care staff trained in mental health Stakeholder involvement. Participation of associations of persons with mental disorders and family members in service planning and development Service availability. Number of mental health care facilities at different levels of service delivery Target 3.1. 80% of countries will have at least two functioning national, multisectoral mental health promotion and prevention programmes (by 2020) Target 3.2. The rate of suicide in countries will be reduced by 10% (by 2020) Objective 4. To strengthen information systems, evidence and research for mental health Target 4. 80% of countries will be routinely collecting and reporting at least a core set of mental health indicators every 2 years through their national health and social information systems (by 2020) Functioning programmes of multisectoral mental health promotion and prevention in existence Inpatient care. Number and proportion of admissions for severe mental disorders to inpatient mental health facilities that a) exceed one year and b) are involuntary Service continuity. Number of persons with a severe mental disorder discharged from a mental or general hospital in the past year who were followed up within one month by community-based health services Social support. Number of persons with a severe mental disorder who receive disability payments or income support
Objective 3. To implement strategies for promotion and prevention in mental health
Number of suicides per year
Core set of mental health indicators routinely collected and reported every 2 years
6
Executive summary
indicators used in Atlas 2014 were formulated and agreed following consultation with the regions and field-testing.
Table 2. Countries that completed the Mental health atlas 2014 questionnaire Afghanistan Bahrain Djibouti Egypt Iran (Islamic Republic of) Iraq Jordan Kuwait Lebanon Libya Morocco Oman Palestine Pakistan Qatar Saudi Arabia Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates Yemen
Methods The Mental health atlas 2014 project was carried out in three stages. In the first stage, the questionnaire was developed in consultation with Member States and regional offices. The final questionnaire was translated into three official UN languages (French, Russian and Spanish), and a completion guide was prepared, which explained terminology and definitions to ensure standardized completion of the questionnaire. During the second stage the questionnaire was disseminated to a focal point, appointed by the ministry of health in each Member State. The focal point completed the questionnaire incorporating information provided by experts in the field and with guidance and support provided by staff at WHO headquarters and regional offices. In the third stage, the completed questionnaires were submitted and checked for inconsistencies or incomplete responses. Focal points were contacted again during clarification and checking of the responses to generate the highest quality data. Table 3. Regional health system groups Group 1 Countries where socioeconomic development has progressed considerably over recent decades, supported by high income Bahrain Kuwait Oman Qatar Saudi Arabia United Arab Emirates Group 2
All countries in the Eastern Mediterranean Region were invited to complete the Mental health atlas 2014 (see Table 2). Data were analysed for the Eastern Mediterranean Region, and comparisons made with global data, and where appropriate comparisons were made with data from Mental health atlas 2011. Rates per 100 000 population were calculated using UN population estimates for 2013. Monetary values where available were standardized to US$, base year 2014. Within the Region comparisons were made based on the regional health system groups.The Regional Office for the Eastern Mediterranean has grouped countries based on broadly similar
Group 3 Countries which face major constraints in improving population health outcomes as a result of lack of resources for health, political instability and other complex development challenges Afghanistan Djibouti Pakistan Somalia Sudan Yemen
Largely middle-income countries which have developed extensive public health service delivery infrastructure but face resource constraints Egypt, Iran (Islamic Republic of) Iraq Jordan Lebanon Libya Morocco Palestine Syrian Arab Republic Tunisia
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Mental health atlas 2014
characteristics in terms of their population health outcomes, health system performance and level of health expenditure (see Table 3). The data reported in this regional review differ in some respect from those in the global Mental health atlas 2014. This review includes data for Palestine, and some data excluded from the global report has been included in this report as it is of regional relevance.
Countries were asked about the presence of a stand-alone or integrated mental health policy and the year of its latest revision. Most countries (68%) have a stand-alone mental health policy (see Figure 1). Two countries (9%) have mental health integrated into other general health or disability policies or plans. Five countries (23%) do not have a mental health policy or plan. Among countries with a stand-alone mental health policy, 12 (55% of all countries) were published or revised within the previous 5 years. The remaining three were all published within the past 12 years.
Results All 22 countries of the Region completed the Mental health atlas 2014 questionnaire, compared with a response rate of 87% from the rest of the world. All countries of the Region reported on some indicators, such as those relating to mental health policy and law. However, for some items the country response rates were very low (e.g. six or fewer countries provided data), for example: mental health spending, service coverage, continuity of care, social support and suicide rates. It is not possible to make meaningful regional analyses with such limited data. Therefore, only a cursory summary of data on these items is included.
5 years 2 years
15 years
Stand-alone mental health policy Integrated mental health policy No mental health policy
1. Mental health policy The first objective of the Comprehensive Mental Health Action Plan is to strengthen leadership and governance for mental health. Leadership and governance are expressed through mental health policy, legislation and provision of resources. Mental health policy is a statement of the values, principles, objectives and areas for action to improve mental health. These may be stand-alone or may be integrated into other general health or disability policies or plans. For the purposes of the Mental health atlas 2014, a policy is considered valid only if it has been approved/published by the ministry of health or parliament.
Figure 1. Number of countries with an approved/ published mental health policy
Number of countries
20 16 12 8 4 0 4 1
17
0
o no t de t a ve va lop ila e bl d/ e Av ail im ab pl le em bu en t n te ot d
Availability of policy/plans for mental health
Figure 2. Current status of policy/plans for mental health
8
Av ai im pa lable r pl ti a em all nd en y te d
Av a im ilab pl le a em n en d fu te lly d
N
Mental health policy
100 Percentage of countries that are compliant
80 60 40 20 0
77
77 55
45
36
Promotes communitybased and integrated services
Explicitly respects human rights
Promotes a full range of services to enable people to live independently
Promotes a recovery approach to mental health care
Promotes participation in decision making processes
Aspects of international human rights instruments
Figure 3. Compliance of mental health policy with human rights instruments (% of all countries in the Eastern Mediterranean Region)
Countries were asked to comment on the current status of implementation of a mental health policy (including both stand-alone and integrated policies). Most (77%) reported that a policy was available and partially implemented (see Figure 2). None was fully implemented. One had a policy available but not yet implemented, and four did not have an available mental health policy. Countries were asked if their policies are compliant with international human rights instruments. Most countries’ policies promote community-based and integrated services and explicitly respect human rights (see Figure 3). More than half promote a full range of services to enable people to live independently. However, less than half promote a recovery approach
to mental health care and participation in decision-making processes.
Progress in presence of a mental health policy or plan between 2011 and 2014 Across the whole Eastern Mediterranean Region and within each health system group, there was little change in the percentage of countries with a stand-alone mental health policy between 2011 and 2014 (see Table 4). In 2014, 11 countries had a mental health policy or plan updated from 2011 onwards, five countries have updated policies/plans in line with all five items of the human rights instruments.
Table 4. Countries with stand-alone mental health policies in 2011 and 2014, by regional health system group Group Eastern Mediterranean Region Health system group 1 Health system group 2 Health system group 3 a
Countries with mental health policy or plan (% of all reporting countriesa) 2011 16 (80%) 6 (100%) 7 (77.8%) 3 (60%) 2014 17 (77.3%) 5 (83.3%) 7 (70%) 4 (66.7%)
The total number of countries reporting these data differed between 2011 and 2014, and hence the percentages for the 2 years have different denominators.
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Mental health atlas 2014
Percentage with mental health policy published or revised in the past five years
60 50 40 30 20 10 0 AFR AMR 42 43
55
56 46 30 36
EMR WHO region
EUR
SEAR
WPR
Figure 4. Percentage of countries in each WHO region that have published or revised their mental health policy in the past 5 years
Comparison of mental health policy in the Eastern Mediterranean Region with the rest of the world Globally, 77% of countries have stand-alone mental health policies. The percentage of countries with stand-alone policies in the Eastern Mediterranean Region (68%) is lower than the global figure. The percentage of countries with mental health policies published or revised in the past 5 years in the 100 90 80 70 60 50 40 30 20 10 0 AFR AMR EMR WHO region 55 84 77
Region (55%) is greater than the global rate of 47% and is among the highest reported by any WHO region5 (see Figure 4). The percentage of countries in which mental health policy is either fully or partially implemented in the Region (77%) is similar to the corresponding global figure of 76%, and the Eastern Mediterranean Region lies in the middle range of WHO regions (see Figure 5). However, when global comparisons are made
Percentage of countries that have partially or fully implemented their mental health policy
89
90
66
36
EUR
SEAR
WPR
Figure 5. Percentage of countries in each WHO region that have partially or fully implemented their mental health policy 5
The WHO regions are: Africa (AFR), Americas (AMR), South-East Asia (SEAR), Europe (EUR), Eastern Mediterranean (EMR) and Western Pacific (WPR).
10
Mental health legislation
Percentage with mental health policy compliant with all five standards of internatonal human rights
80 70 60 50 40 30 20 10 0 AFR AMR EMR WHO region 41 32 63
74 59 44 36
EUR
SEAR
WPR
Figure 6. Percentage of countries in each WHO region that have mental health policies that are compliant with all five standards of international human rights
of full implementation rates, the Region has the lowest rate of 0% (compared with highs of 28% in the European Region and 30% in South-East Asian Region). The Eastern Mediterranean Region compares less favourably with the rest of the world for compliance of mental health policies with international human rights: 45% of countries of the Region are compliant with more than three standards of international human rights, compared with 72% of all world countries. Seven (32%) countries of the Region are compliant with all five human rights standards, compared with 56% of all world countries (see Figure 6). Compared with other WHO regions, the Eastern Mediterranean Region has the lowest compliance with international human rights.
stand-alone, or may be integrated into other general health or disability laws. Countries were asked about the presence of stand-alone or integrated mental health legislation and the year of its latest revision. Most countries have a stand-alone mental health law (see Figure 7). Four countries have mental health integrated into other general health or disability laws. Five countries do not have a mental health law.
1 5 12 4
2. Mental health legislation Mental health legislation is legislation specifically related to mental health that protects the civil and human rights of people with mental disorders and addresses treatment facilities, personnel, professional training and service structure. Mental health law may be Stand-alone mental health law Integrated mental health law No mental health law Stand-alone law soon to be enacted
Figure 7. Number of countries with mental health legislation
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Mental health atlas 2014
6 5 Number of countries 4 3 2 1 0 1 1 2 5 Number of countries
9 8 7 6 5 4 3 2 1 4
8
8
2
19 50 s
19 60 s
19 70 s
19 80 s
19 90 s
20 00 s
20 10 s
0
Figure 8. Decade that the mental health law was enacted
Among countries with a stand-alone mental health law who provided data on year of enactment, five were enacted/revised within the past 5 years (see Figure 8). The remaining four were enacted more than 10 years ago, including one that dates back to 1959. One further country has stand-alone legislation that is about to be enacted. Countries were asked to indicate the current status of implementation of their mental health legislation (including both stand-alone and integrated laws). Two (9%) reported that their
Figure 9. Status of the law covering mental health
mental health laws are fully implemented (see Figure 9). In 18% of countries of the Region, mental health legislation is not developed/ available and in a further 36% of countries it is available but not implemented. 59% of countries indicated that their mental health legislation is compliant with international human rights instruments in that they promote rights to exercise capacity and
100 Percentage of countries
80 60 40 20 0 Promotes transition to mental health services in the community Promotes rights to Promotes alternatives to Provides to protect exercise capacity and coercive practice rights and file appeals nominate a trusted and complaints to person to support them independent legal body Aspects of international human rights instruments Provides for regular inspection of human rights conditions by an independent body 59 45 59 59 45
Figure 10. Compliance of mental health law with international human rights instruments (% of all countries of the Region)
12
N o no t de t a ve va lop ila e bl d/ e Av ail im ab pl le em bu en t n te ot d Av ai im pa lable pl rti a em all nd en y te d Av ail im ab pl le a em n en d fu te lly d Availability of laws covering mental health
Mental health legislation
Table 5. Countries of the Region with stand-alone mental health legislation in 2011 and 2014, by regional health system group Group Presence of stand-alone mental health legislation (% of all countries) 2011 Eastern Mediterranean Region Health system group 1 Health system group 2 Health system group 3 11 (55%) 2 (33.3%) 7 (77.8%) 2 (40%) 2014 12 (54.5%) 2 (33.3%) 7 (70%) 2 (33.3%)
nominate a trusted person to support them; promote alternatives to coercive practice; and provide to protect rights and provide appeals and complaints to independent legal bodies (see Figure 10). Just under half of the countries in the Region indicated that their legislation promotes transition to mental health services in the community and provides for regular inspection of human rights conditions by an independent body.
Six countries of the Region have developed or updated their mental health legislation between 2011 and 2014.
Progress in the presence of stand-alone mental health legislation between 2011 and 2014 Across the whole Eastern Mediterranean Region and within each health system group, there was little change in the percentage of countries with stand-alone mental health legislation between 2011 and 2014 (see Table 5).
Comparison of mental health legislation in the Eastern Mediterranean Region with the rest of the world Globally, 63% of countries have stand-alone mental health legislation. The percentage of countries with stand-alone legislation in the Eastern Mediterranean Region (55%) is slightly lower than the global figure. The percentage of countries with mental health legislation published or revised in the past 5 years in the Region (23%) is greater than the corresponding global rate of 18% and is the third highest among WHO regions (see Figure 11).
Percentage with mental health legislation published or revised in the past 5 years
40 35 30 25 20 15 10 5 0 3 AFR AMR EMR WHO region EUR SEAR 7 23 25 20
38
36
WPR
Figure 11. Percentage of countries in each WHO region that have passed or revised their mental health legislation in the past 5 years
13
Mental health atlas 2014
Percentage of countries that have partially or fully implemented their mental health legislation
100 90 80 70 60 50 40 30 20 10 0 AFR AMR EMR WHO region 53 45 76
87 78
50
36
EUR
SEAR
WPR
Figure 12. Percentage of countries in each WHO region that have partially or fully implemented mental health legislation
The percentage of countries in which mental health legislation is either fully or partially implemented in the Region (45%) is lower than the corresponding global figure of 69% and is lower than other WHO regions (see Figure 12). Eleven or 55% of reporting countries of the Region are compliant with more than three
standards of international human rights, compared with 61% of all world countries. Six or 25% of reporting countries of the Region are compliant with all five standards of international human rights, compared with 42% of all world countries. The Eastern Mediterranean Region ranks fifth (out of six regions) most compliant with international human rights (see Figure 13).
Percentage with mental health legislation compliant with all five standards of internatonal human rights
60 50 40 31 30 20 10 0
54
57
33 25 22 36
AFR
AMR
EMR WHO region
EUR
SEAR
WPR
Figure 13. Percentage of reporting countries in each WHO region that have mental health legislation which is compliant with all five standards of international human rights
14
Stakeholder involvement
Box 1. Domains of involvement of associations of persons with mental disorders and family members in the formulation and implementation of mental health policies, laws and services 1. Information: ministry of health gathers and disseminates information about organizations of persons with mental and psychosocial disabilities and of families and carers. 2. Policy: ministry of health has developed and published a formal policy on the participation of persons with mental and psychosocial disabilities in the formulation and implementation of mental health policies, plans, legislation and services. 3. Early involvement: persons with mental and psychosocial disabilities, as well as families and carers, are involved from the beginning of the formulation and implementation of mental health policies and laws, and given adequate notice. 4. Participation: ministry of health systematically involves persons with mental and psychosocial disabilities in planning, policy, service development and evaluation: the majority of committees and subcommittees developing the above areas have representation from an organization of persons with mental and psychosocial disabilities or at least one person with a mental and psychosocial disability. 5. Resources: ministry of health reimburses costs of participation of persons with mental and psychosocial disabilities and provides resources to allow participation (physical location, transport, remuneration or reimbursement of expenses, interpreters, attendant carers and meeting support personnel).
3. Stakeholder involvement Countries were asked to indicate the level of involvement of associations of persons with mental disorders and family members in the formulation and implementation of mental health policies, laws and services at a national level in the past 2 years. This was done on a three-point scale (not implemented; partially implemented; fully implemented) for five domains: information, policy, early involvement, participation and resources (see Box 1). 24 Percentage of countries 20 16 12 8 4 0 31 4 6 6 3 31 17 16 16 16
In all domains, most countries reported that measures are not implemented (see Figure 14). In about one-quarter of countries, measures were partially implemented. Full implementation was rarely reported; in only one country for the domains of information, policy and resources; and in no countries for early involvement and participation.
inv ol
rly
Pa
Re
Comparison of stakeholder involvement in the Eastern Mediterranean Region with the rest of the world Compared with the rest of the world, the Eastern Mediterranean Region has a lower level of involvement of associations of service users and their families, and this is evident for partial or full implementation in all five stakeholder involvement domains (see Figure 15). When compared with other WHO regions, the Eastern Mediterranean Region ranked fifth (of six regions) for the domain of policy, and ranked sixth (of six regions) for information, early involvement, participation and resources. Stakeholder involvement is an aspect of mental health services that is particularly underdeveloped in almost all countries of the Region, and therefore there are opportunities to develop partnerships to catalyse and influence change in the planning and delivery of mental health services. 15
n
icy
t
en
io
n
tio
ve m
fo r
ici
In
Aspects of implementation of stakeholder involvement Fully implemented Partially implemented Not implemented
Figure 14. Implementation of stakeholder involvement
Ea
rt
so
ur ce
Po l
at
m
pa
s
Mental health atlas 2014
80 70 Percentage of countries 60 50 40 40 20 10 0 Information Policy Early involvement Participation Global Resources 23 27 27 23 50 67 58 50 43 57
Eastern Mediterranean Region
Figure 15. Comparison of the percentage of reporting countries in the Eastern Mediterranean Region and globally that have partially or fully implemented involvement of persons with mental disorders and family members in the formulation and implementation of mental health policies, laws and services at national level in the past 2 years
4. Government mental health spending The government is the main source of mental health care and treatment funding in most countries in the Eastern Mediterranean Region (see Figure 16), which is similar to the sources of funding found in the rest of the world. Less than half of the countries reported on the annual government spending on the various component settings of their mental health services (see Figure 17). Annual spending on mental hospitals was reported by six (27%) countries. Spending on other components was reported by fewer countries. That countries are unable to provide a breakdown of spending suggests that specific budgets may not be set aside for mental health services. The small number of countries able to provide costing data limits the use of regional analysis for most components of the mental health system. However a tentative comparison of annual mental hospital spending shows considerable variation from less than one US cent per person in Pakistan, up to US$ 22 per
person in Bahrain. A group 1 country (Qatar) has the highest per capita expenditure on mental hospitals among reporting countries, and a group 3 country (Pakistan) has the lowest expenditure. 14 12 Number of countries 10 8 6 4 2 2 0 1 7 12
Sources of funding for care and treatment of severe mental disorders
Figure 16. Main overall source of funds for care and treatment of severe mental disorders
16
N on
go or ver ga nm ni e za nt tio al ns N ot re po rt ed
en
nm
G ov er
H
ou
se
ho
ld
s
t
Government mental health spending
8 7 Number of countries
6
6 5 4 3 3 2 1 1 2 1 1 3 5
4
2
0 ac ilit O ies th er r nd es ide M pr en nt im ial ta a ry lh ea he lth alt h ou ca tp re Pr at im ien ar t yh fac Co ilit ea m lth ies m un ca ity re fac ca re ilit or ies r O eh th a bil er ita ou tio tp n at ien tf ac So ilit cia ies lc a O r e th se er rv pr ice og s ra m m e co sts pit al pit al ice s se rv lh os ho s fac en tf ilit ies To ta l
M en ta l
ge ne ra
ar d
In pa tie nt a
m un ity
hia tri cw
D
ay tre at m
da yc
nd
re sid
in
en tia l
ar e
Figure 17. Number of countries reporting annual government spending on component mental health care settings
O ut pa tie nt a
Ps yc
Co
m
Components of mental health services
Comparison of government mental health spending in the Eastern Mediterranean Region with the rest of the world The government (e.g. national health insurance or reimbursement schemes) is ranked as the main overall source of funds for care and treatment of severe mental disorders in 79% Percentage of countries in which government funding is the main source of funding for care and treatment of severe mental disorders
of world countries, compared with 80% of the reporting countries of the Region. The Eastern Mediterranean percentage is similar to those of the Americas Region and the Western Pacific Region, lower than those of the European Region and South-East Asian Region, but higher than that in the African Region (see Figure 18). 100
100 90 80 70 60 50 40 30 20 10 0 AFR AMR EMR WHO region EUR 67 78 79 86
77
36
SEAR
WPR
Figure 18. Percentage of reporting countries in which government funding is ranked the number one overall source of funds for care and treatment of severe mental disorders by WHO region
17
Mental health atlas 2014
60 50 Percentage of countries
49 42
51 45 34 22 36 31 23 26 23 23 27 40 37 31
40 30 20 10 0
34 27 22 25 28
32 32
9 4 Inpatient Mental hospital 4
9 4 Outpatient Total
Components of mental health services AFR AMR EMR EUR SEAR WPR Global
Figure 19. Percentage of countries in each WHO region and globally that provided per capita government mental health expenditure
23% of all countries of the Region provided government mental health spending per capita in the past year compared with 31% of countries globally (see Figure 19). For inpatient services, mental hospitals and outpatient services, the percentage of countries in the Eastern Mediterranean Region providing data was within 2 percentage points of the percentage of countries providing comparable data globally. As noted above the government funding data available for the countries of the Region is based Median government funding of mental health inpatient and day care services (in US$) 60.00 50.00 40.00 30.00 20.00 10.00 0.00 0.09 AFR 1.64 AMR 0.45 EMR EUR 0.96 SEAR WPR 49.42
on a small number of countries, and therefore comparisons with other WHO regions has to be extremely cautious. The following four figures use the available data to provide a very rough indication of how the government funding of mental health services in the Eastern Mediterranean Region compares with the rest of the world. The median government funding of mental health inpatient and day care services in reporting countries of the Region is US$ 25.00 Median government funding of mental hopitals (in US$) 20.00 15.00 10.00 5.78 5.00 0.00 3.61 1.35 0.48 AFR AMR EMR EUR SEAR WPR 19.65 18.49
35.54
WHO region
WHO region
Figure 20. Median government funding of mental health inpatient and day care services in US$, by WHO region
Figure 21. Median government funding of mental hospitals in US$, by WHO region
18
Mental health workforce
80.00 Median government funding of mental health outpatient services (in US$) 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 0.00 AFR AMR 6.47 0.09 EMR EUR 0.09 SEAR 24.80
72.11 Median government funding of mental health outpatient services (in US$)
140.00 120.00 100.00 80.00 60.00 40.00 20.00 0.00 0.12 AFR AMR 0.70 EMR EUR 1.17 SEAR WPR 33.42 96.89 116.66
WPR
WHO region
WHO region
Figure 22. Median government funding of mental health outpatient services in US$, by WHO region
Figure 23. Median total government funding for mental health services in US$, by WHO region
0.45, which is very low in comparison with the global median of US$ 29.93. The Eastern Mediterranean Region ranks fifth of the six WHO regions for government spending on mental health inpatient and daycare services (see Figure 20). The median government funding of mental hospitals in countries of the Region is US$ 5.78, which is half of the global median of US$ 11.02. The Eastern Mediterranean Region ranks third of the six WHO regions for government spending on mental hospitals (see Figure 21). The median government funding of mental health outpatient services in reporting countries of the Region is US$ 0.09, which is very low in comparison with the global median of US$ 24.28. The Eastern Mediterranean Region ranks fourth of the six WHO regions for government spending on mental health outpatient services (see Figure 22). The median total government funding for mental health services in reporting countries of the Region is US$ 0.70, which is very low in comparison with the global median of US$ 72.57. There is an apparently discrepancy that the reported figures for spending on
mental hospitals exceed the amount reported for total mental health funding; this discrepancy has arisen because of poor response rates to the financing items in the Atlas questionnaire, and the group of countries that reported total government funding was different from the group of countries that reported on mental hospital spending. This emphasizes the caution required interpreting these financial data. The Eastern Mediterranean Region ranked fifth of the six WHO regions for total government spending on mental health services (see Figure 23).
5. Mental health workforce Countries were asked to estimate the total numbers of mental health professionals working in each country by profession. Across the Eastern Mediterranean Region, nurses (including both psychiatric nurses and general nurses working in mental health facilities) make up the largest professional group among the mental health workforce, followed by psychiatrists, psychologists and social workers (see Figure 24). There is approximately one psychiatrist for every four nurses, one psychologist for every six nurses and one social worker for every 16 nurses. 19
Mental health atlas 2014
6 Median rate per 100 000 population 5.18 5 4 3 2 1 0 Nurses Psychiatrists Psychologists Social workers
1.31
0.89 0.32 0.18 Other health or mental health workers 0.12 Other medical doctors 0.01 Occupational therapists
Type of mental health professional
Figure 24. Median rate of health professionals per 100 000 population
Other health and mental health workers, other medical doctors and occupational therapists are relatively uncommon. Comparing human resources in 2011 and 2014 (see Table 6) suggests that there have been increases in some specialist staff groups such as nurses, psychiatrists and psychologists; while occupational therapists, other medical doctors and other health or mental health workers have reduced in number across the Region as a whole. The regional averages of the mental health workforce conceal specific changes in individual countries. For example, there have
been substantial increases in the number of nurses working in mental health in Bahrain, Kuwait, Morocco, Oman and Pakistan; while the numbers of nurses per 100 000 population has decreased in Lebanon, Qatar, Saudi Arabia and Syrian Arab Republic (see Figure 25). The nursing workforce is numerically stronger in health system group 1 countries compared with group 2 countries. Increases in the mental health nursing workforce between 2011 and 2014 are apparent in group 1 and group 2 (see Figure 26).Too few group 3 countries provided information to allow meaningful comparison.
Table 6. Median rate of health professionals per 100 000 population Type of professional Nurses (including both psychiatric nurses and general nurses working in mental health facilities) Psychiatrists Psychologists Social workers Other health or mental health workers working in mental health facilities Other medical doctors not specializing in psychiatry Occupational therapists 2011 3.3 0.86 0.41 0.47 4.35 0.28 0.04 2014 5.18 1.31 0.89 0.32 0.18 0.12 0.01
20
Mental health workforce
Number of nurses per 100 000 population
25 20 15 10 5 0 0.1
22.7 19.2 15.4 12.7 8.8 4.7 1.5 0.8 4.1
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* Only countries with data for both 2011 and 2014 are included
Figure 25. Number of nurses per 100 000 population by country* in 2011 and 2014
Median rate of psychiatrists per 100 000 population
Increased investment in the mental health workforce in group 1 countries between 2011 and 2014 is also reflected in the increase in numbers of psychiatrists (see Figure 27); but this is not seen in group 2 countries.
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Median rate of nurses working in mental health facilities per 100 000 population
14 12 10 8 6 4 2 0 10.71
12.71 2011 2014
Figure 27. Median rate of psychiatrists per 100 000 population in 2011 and 2014 by regional health system group
3.6 2.37
Group 1
Group 2
Figure 26. Median rate of nurses working in mental health facilities per 100 000 population in 2011 and 2014 by regional health system group
Comparison of mental health workforce in the Eastern Mediterranean Region with the rest of the world The average total mental health workforce in the Eastern Mediterranean Region is 14.6 per 100 000 population. This is less than half the comparable global rate of 33.8 per 100 000 population.The Eastern Mediterranean Region 21
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Mental health atlas 2014
90 80 Total mental health workforce per 100 000 population 70 60 50 40 30 20 10 0 4.7 AFR AMR EMR EUR 14.6 3.7 SEAR WPR 19 42.3 77.6
WHO region
Figure 28. Total mental health workforce per 100 000 population by WHO region
and is therefore different from the median figure quoted earlier in this section. Table 7 indicates that compared with the rest of the world, the Eastern Mediterranean Region has above the average number of other medical doctors working in mental health. The Eastern Mediterranean Region is just below the global average for other paid workers working in mental health. The number of nurses per 100 000 population in the Region is about half the global average, and slightly lower for psychiatrists.The Region has less than a quarter of the global average number of psychologists, social workers and occupational therapists per 100 000 population.
is ranked fourth among the WHO regions for the size of its mental health workforce per 100 000 population (see Figure 28). There is a large difference in workforce between WHO regions from the lowest of 3.7 and 4.7 per 100 000 in the South-East Asia Region and the African Region respectively to the highest of 77.6 in the European Region. Table 7 shows the average number of the various types of mental health staff per 100 000 population in each WHO region and globally and also indicates the rank of the Eastern Mediterranean Region compared with the other WHO regions. The figure quoted in the table is the mean within each region
6. Mental health training in primary care Primary care staff are the cornerstone of mental health care. The Atlas 2014 questionnaire asked countries to report the numbers of primary care staff, by profession, who had been trained in mental health care for at least two days in the past 2 years. These numbers were divided by WHO estimates of the total workforce of doctors, nurses and community health workers in each country (the total workforce, not just the primary care workforce). Twelve countries of the Region were able to provide data on training of doctors, and seven provided data on training for nurses and midwives (see Table 8).
Table 7. Average number of mental health staff per 100 000 population in each WHO region and globally Mental health staff Psychiatrists Other medical doctors Nurses Psychologists Social workers Occupational therapists Other paid workers AFR 0.3 0.2 2.1 0.6 0.1 0.3 1.0 AMR 3.5 1.6 15.8 5.6 9.0 0.8 14.2 EMR 1.7 4.7 7.9 1.0 0.7 0.2 10.5 EUR 10.5 5.1 31.6 11.2 2.8 3.2 29.0 SEAR 0.7 0.4 1.5 0.3 0.1 0.1 1.0 WPR 1.6 1.4 12.2 1.9 1.2 0.6 4.0 Global 4.2 2.4 14.4 4.6 2.9 1.1 12.4 EMR rank 3 2 4 4 4 5 3
22
Mental health training in primary care
Table 8. Percentage of primary care staff trained in mental health at least 2 days in the past 2 years (by type of professional) Primary care staff Doctors Nurses and midwives Number of countries reporting 12 7 Median (%) 2.7 1.6 Range (%) 0.3–29.2 0.01–51.0
Overall, only a small minority of doctors (2.7%), and nurses and midwives (1.6%) had received training. There was a wide range between countries in the percentage of primary care staff receiving mental health training in the past 2 years. The countries in which the greatest percentage of both doctors and nurses and midwives had received training is in group 3. In Atlas 2014, countries were asked to indicate the numbers and proportions of primary care staff trained in mental health for at least two days in the past 2 years. This question is substantially different from the question asked in Atlas 2011, which asked about the broad proportion of doctors and nurses who had received official in-service training on mental health within the past 5 years; therefore direct
comparisons between the two atlases are not possible.
Comparison of mental health training in primary care in the Eastern Mediterranean Region with the rest of the world The median percentage of primary care physicians globally who have received training in mental health for at least 2 days in the past 2 years is 2.1%, and the corresponding figure for nurses and midwives is 1.7%. The Eastern Mediterranean Region is therefore slightly above the global median for training of primary care physicians and slightly below the median for training of nurses and midwives. Compared with the other WHO regions, the Eastern Mediterranean Region ranks second for the training of physicians and fourth for the training of nurses and midwives (see Figure 29).
Percentage of primary care staff trained in mental health for at least 2 days in the past 2 years
4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 AFR AMR EMR WHO region Physicians/doctors Nurses and midwives EUR SEAR WPR 0.6 0.6 2.4 2.4 2.7 2.0 1.6 1.4 0.9 2.5 4.0 3.4
Figure 29. Percentage of primary care staff trained in mental health for at least 2 days in the past 2 years, by WHO region
23
Mental health atlas 2014
7. Service availability Residential facilities for persons with mental health problems are provided in mental hospitals, psychiatric wards in general hospitals and community residential facilities. There is at least one mental hospital in each country of the Eastern Mediterranean Region, with the exception of Djibouti, where all the mental health beds are in psychiatric wards in a general hospital.6 The average size of the mental hospitals varies between 14 beds (Lebanon) and 779 beds (Pakistan) with a median capacity of 220 beds. In 14 countries (82% of reporting countries) the size of the mental hospitals is between 100 and 620 beds. There is at least one psychiatric ward in a general hospital in 14 countries in the Region. These are typically much smaller units than the mental hospitals, with average sizes ranging between three beds (Oman) and 60 beds (Djibouti) with a median capacity of 17 beds. Five countries (23%) reported that they have mental health community residential facilities, and the numbers varied widely between one in Qatar and Tunisia; through seven in Lebanon, up to 93 in Islamic Republic of Iran and 344 in Pakistan. The average size of community residential facilities in countries varies between six and 124 beds with a median of 33 beds. Eight countries (36%) reported that they have mental health day care or treatment facilities. Most of these countries have only one or two such facilities, but day treatment is more extensively developed in Islamic Republic of Iran, Tunisia and Pakistan, where there are 117, 48 and 14 day care facilities respectively. Islamic Republic of Iran also has the largest average capacity of day care facilities of 46 places. The median number of places in a day care facility across the countries of the Region which have them is ten. 6
Eighteen countries (82%) reported on the number of mental health outpatient facilities available in the country. The median number of patients seen in a mental health outpatient facility in the Region is 100 per week.
Availability of beds per 100 000 population Throughout the Region there is a median of 6.1 psychiatric beds per 100 000 population. This rate varies between 0.8 and 19.8 per 100 000 with higher rates in group 1 countries (see Figure 30). The median number of all psychiatric beds per 100 000 population decreased from 7.0 in 2011 to 6.1 in 2014. The median number of mental hospital beds per 100 000 population is 4.48 (range 0–19.5); and the median number of psychiatric beds in general hospitals per 100 000 population is 0.49 (0–6.8). The majority of countries in the Region do not have community residential facilities, but among the four that do, the median number of beds per 100 000 population is 1.2 (0.4–6.7). Within the Region, 64.3% of psychiatric beds are located in mental hospitals and 35.7% are located in community settings: general hospitals (18.3%) and community residences
12 Median rate of psychiatric beds per 100 000 population 10 8 6 4 2 0
11.3
6.4
1.7
Group 1
Group 2
Group 3
Somalia did not report on service availability.
Figure 30. Median rate of psychiatric beds per 100 000 population by regional health system group
24
Service availability
(17.4%). This distribution is almost unchanged from that found in 2011 (see Figure 31). There remains a wide variation between countries in the extent to which their psychiatric beds are located in community settings, such as general hospital and community residential facilities (see Figure 32). In several countries the percentage of mental health beds that are in 100 90 Percentage distribution of mental health beds 80 70 60 50 40 30 20 10 0 2014 2011 Year of Mental health atlas Community residential General hospital Mental hospital 66 64.3 16 18 17.4 18.3
general hospitals and community residences fell between 2011 and 2014 (Jordan, Oman, Qatar, Saudi Arabia, Sudan, Syrian Arab Republic and Tunisia). Due to the small number of countries reporting, we cannot usefully compare beds available in community residential facilities in 2011 and 2014 at a regional level. At an individual country level, most have remained at a similar level, but in Pakistan (group 3) there has been a substantial development from zero in 2011 to 1.2 per 100 000 in 2014.
Availability of day care or treatment facilities per 100 000 population In 2011, in the countries with day care facilities, there was a median of 0.005 day care facilities per 100 000 population. In 2014, the corresponding figure for the Region is still 0.005 day care facilities per 100 000, which indicates that day treatment remains relatively underdeveloped in the Region. Availability of outpatient facilities per 100 000 population Outpatient facilities comprise hospital outpatient departments, mental health
Figure 31. Distribution of mental health beds in the Eastern Mediterranean Region in 2011 and 2014
Percentage of all psychiatric beds
100 90 80 70 60 50 40 30 20 10 0 00 5 0 25 21 50 47 54 51 31 8 00 35 33 16 3 0 4 8 0 20 13 10 1 64 62 86
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66 48 30 24 14 14 9
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Figure 32. Percentage of all psychiatric beds that were in general hospital and community residences in 2011 and 2014 – countries shown are those with relevant data for both 2011 and 2014
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Mental health atlas 2014
outpatient clinics, community mental health centres and community-based mental health care facilities. In 2011, there was a median of 0.28 outpatient facilities per 100 000 population in the countries of the Region, which was about half the global rate. In 2014, the corresponding figure for the Region was 0.15 outpatient facilities per 100 000, which is lower than in the previous Atlas survey. The median number of outpatient visits per 100 000 has gone up from 279 per 100 000 in 2011 to 1275 per 100 000 in 2014. At first sight, this seems at odds with the minimal change in the number of facilities. However, some countries in the Region have reported that the capacity of their outpatient services was not fully used in 2011 but use has subsequently risen, thus greatly increasing the number of outpatient visits to a relatively stable number of outpatient facilities. A further possible explanation is that although 18 countries reported on the number of facilities in 2014, only 12 reported on the number of outpatient visits. Missing data on the number of visits may
have biased the reported median number of outpatient visits per 100 000.
Comparison of service availability in the Eastern Mediterranean Region with the rest of the world Compared with global rates, the Eastern Mediterranean Region has relatively low provision of psychiatric beds. The median number of mental hospital beds per 100 000 in the Region of 4.78 is lower than the global median of 6.5 per 100 000 and ranks third compared with other WHO regions (see Figure 33). The Region has fewer psychiatric beds in general hospitals (0.49 per 100 000 compared with 2.14 globally), and beds in community residential facilities (median of 0 per 100 000 compared with 0.15 globally), and ranks fifth and sixth respectively compared with other WHO regions. There is a median of 0.02 day care places per 100 000 in the Eastern Mediterranean Region, which is lower than the global median of 0.01 per 100 000. However, the rate of 0.02 per 100 000 is equal or higher than other WHO regions except the European Region, which
35.0 Beds per 100 000 population 30.0 25.0 20.0 15.0 10.0 5.0 0.0 1.9 AFR 8.7 4.8 0.1 0.8 0.1 AMR 0.5 0.0 EMR
34.5
10.8 6.3 2.1 EUR WHO region 0.6 SEAR 2.1 3.5 2.2 2.4 WPR
Mental hospital
Psychiatric beds in general hospital
Community residential care beds
Figure 33. Psychiatric beds per 100 000 population in mental hospitals, general hospitals and community residential facilities, by WHO region
26
Service coverage for severe mental disorders
8000 7000 Median number of outpatient visits per 100 000 population 6000 5000 4000 3000 2000 1000 0 14 AFR AMR EMR EUR 1165 990 320 SEAR WPR 2321 6688
8. Service coverage for severe mental disorders Coverage is a measure of the number of persons in need who receive care. The Atlas 2014 collected information about coverage of all mental disorders and three forms of severe mental disorder: non-affective psychosis, bipolar affective disorder and moderate– severe depression. The sum of persons with severe mental disorders who received care in the previous year from inpatient and outpatient facilities has been divided by the whole population to give a reasonable estimate of treated prevalence. From among the 22 Eastern Mediterranean Region countries that completed the Atlas questionnaire, relatively few were able to provide these data (see Table 9). For most settings, fewer than five countries provided data. Regional analysis of such limited data is not presented here. Cautious analysis of settings with data from five or more countries is presented - median values based on these small numbers of countries should be regarded only as a rough indication.
WHO region
Figure 34. Median number of outpatient visits per 100 000 population, by WHO region
is the WHO region in which day treatment is most extensively developed. The median rate of 990 outpatient visits per 100 000 population in the Region is similar to the global median of 1051 per 100 000, and ranks fourth when compared with other WHO regions (see Figure 34).
Table 9. Number of countries that provided information about the number of persons with mental disorders who received mental health care in the past year Care setting Inpatient and day care services Mental hospital Psychiatric ward in a general hospital Mental health community residential facility Mental health day treatment facility Other residential facility Outpatient and primary health care services Mental health outpatient facility Primary care facility / clinic Other outpatient health facility or service (e.g. outreach service) Social care services Community care or rehabilitation facility (e.g. day care centres) 2 2 2 2 8 5 5 4 1 3 4 1 3 4 1 3 13 9 5 5 3 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 All mental disorders (common and severe) Non-affective psychosis Bipolar affective disorder Moderate–severe depression
27
Mental health atlas 2014
Table 10. Median treated prevalence per 100 000 population for settings with responses from five or more countries of the Eastern Mediterranean Region Care setting Mental hospitals Type of mental disorder All mental disorders Non-affective psychosis Bipolar affective disorder Moderate–severe depression Psychiatric wards in general hospitals Mental health day treatment facilities Mental health outpatient facilities All mental disorders All mental disorders All mental disorders Number of countries 13 5 5 5 9 5 8 Median 54 28 5 26 29 6 1158 Minimum 5 3 0.2 0.2 0 0 37 Maximum 1151 555 338 259 1017 9.5 3937
The median treated prevalence of all mental disorders in mental hospital is 54 per 100 000 population, and in psychiatric wards of general hospitals is 29 per 100 000 population (see Table 10). The treated prevalence of all mental disorders in mental health outpatient facilities (1158 per 100 000 population) is almost 14 times greater than in the two hospital settings combined. This indicates that from among every 14 patients seen as outpatients, one is likely to be admitted. Among mental hospital treated patients, the treated prevalence of non-affective psychosis 100 90 80 70 60 50 40 30 20 10 0 44 25 10 30 51 38 56 28 87 45 40 34
and moderate–severe depression are similar (28 and 26 per 100 000 respectively), and both are about five times more frequent than bipolar affective disorder (5 per 100 000).
9. Inpatient care Length of stay Ten countries provided data on length of stay in mental hospitals. In the majority of countries, lengths of stay are most often less than one year (see Figure 35). There are substantial percentages staying 1 to 5 years in Iraq, Syrian 2 3
Percentage breakdown of length of stay
13
10 10
8 37
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Figure 35. Percentage breakdown of length of stay for inpatients staying in mental hospitals on 31 December of the most recent year for which countries had data to report (most were 2013)
28
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70 Percentage of patients with length of stay more than five years 60 50 40 30 20 10 0 2011 Year of Mental health atlas 2014 Iran (Islamic Republic of) Jordan Kuwait Lebanon Palestine Pakistan Qatar Syrian Arab Republic
Figure 36. Percentage of patients with length of stay more than 5 years reported in the Atlas 2011 and Atlas 2014 surveys
Arab Republic, United Arab Emirates and Lebanon; and longer stays of more than 5 years occur most frequently in Jordan, United Arab Emirates, Iraq and Lebanon. Eight countries provided length of stay data for both Atlas 2011 and Atlas 2014. The changes in percentage of patients with lengths of stay greater than 5 years are shown in Figure 36. In Lebanon, Palestine and Kuwait the percentage 90 Percentage of patients with length of stay more than five years 80 70 60 50 40 30 20 10 0 2011 Year of Mental health atlas
of patients with length of stay greater than 5 years fell between 2011 and 2014. In Islamic Republic of Iran and Pakistan it has remained low and constant. In Qatar and Jordan the percentage of patients staying more than 5 years has increased. Figure 37 shows a similar graph for length of stay more than 1 year. The percentage of patients staying more than 1 year has fallen in
Iran (Islamic Republic of) Jordan Kuwait Lebanon Palestine Pakistan Qatar Syrian Arab Republic
2014
Figure 37. Percentage of patients with length of stay more than 1 year reported in the Atlas 2011 and Atlas 2014 surveys
29
Mental health atlas 2014
Percentage of total admissions to mental hospitals that are involuntary
100 90 80 70 60 50 40 30 20 10 0 44 1 7 25 17 26 33 36 38 49
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Figure 38. Percentage of total admissions to mental hospitals that are involuntary
Lebanon, Palestine and Kuwait. It is low and slightly reduced in Islamic Republic of Iran and Pakistan. In Jordan, Qatar and Syrian Arab Republic the percentage of patients with length of stay more than 1 year increased between 2011 and 2014.
Involuntary admissions Ten countries provided data on involuntary admissions to mental hospitals. A median of 26% of admissions across the region are involuntary, with a range from 1% to 95% (see Figure 38).
The number of countries providing data on general hospitals and community residential facilities is very small. Four countries provided data on involuntary admissions to general hospitals (Djibouti 71%; Lebanon 60%; Pakistan 2%; United Arab Emirates 4%). One country, Pakistan, provided data on involuntary admissions to community residential facilities (34%). Globally, 11.6% of all admissions were involuntary, suggesting that the percentage of admissions that are involuntary in the Eastern Mediterranean Region is higher than the global average.
Table 11. Percentage of discharged patients who were followed up within 1 month Country Percentage of patients discharged from hospital who had a follow-up visit within 1 month Mental hospital Afghanistan Djibouti Jordan Palestine Pakistan United Arab Emirates 1 Not applicable 55 100 54 85 General hospital 59 92 74 Not applicable 42 100
30
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Suicide prevention
Table 12. Persons with mental disorders who received social support in the past year Country Number of persons with mental disorders who received social support in the past year per 100 000 population Monetary support Bahrain Djibouti Iraq Pakistan United Arab Emirates 300 17 4 0.1 1.3 Non-monetary support Unknown Unknown Unknown 36 0.02
10. Continuity of care after discharge Six countries provided data about the number of persons who had a follow-up visit within 1 month of discharge from mental hospital and from psychiatric wards in general hospitals (see Table 11).
the Region provided data on the number of persons with mental disorders who received social support in the past year (see Table 12).
12. Mental health promotion and prevention The third objective of the Comprehensive Mental Health Action Plan concerns the implementation of strategies for promotion and prevention in mental health. National mental health promotion and prevention programmes exist in 10 (45%) countries in the Eastern Mediterranean Region (see Figure 39).
11. Social support Countries were asked to report on the number of persons who had received social support, such as disability payments, income support or forms of non-monetary support, such as housing support, access to employment and educational assistance. Only five countries of 8 Number of mental health promotion and prevention programmes reported 7 6 5 4 3 2 1 0
an
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Figure 39. Number of mental health promotion and prevention programmes reported by countries
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Mental health atlas 2014
60 Percentage with more than one mental health or promotion programme 50 40 32 30 20 10 0 31 41 51 45 52
Table 13. Crude suicide rates Country Bahrain Iran (Islamic Republic of) Palestine Pakistan Tunisia Crude suicide rate per 100 000 per year 1.6 2.5 0.7 4.4 0.4
AFR
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EUR
SEAR
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WHO region
Figure 40. Percentage of countries in each WHO region with more than one mental health prevention and promotion programme
In many countries throughout the world, vital registration systems are poorly developed and consequently there are issues of underreporting of suicide. Five countries reported the number of suicide deaths (seeTable 13).All of these rates are lower than the global, age-standardized suicide rate of 11.4 per 100 000 population.
Comparison of mental health promotion and prevention in the Eastern Mediterranean Region with the rest of the world Globally, 41% of countries have mental health promotion and prevention programmes, which is the same percentage as in the Eastern Mediterranean Region. The Region is correspondingly positioned in mid-range for percentage of countries with more than one prevention and promotion programme when compared with the other WHO regions (see Figure 40).
14. Core mental health indicator set Specific reports on mental health activities have been produced in half of the countries in the Eastern Mediterranean Region in the past 5 years (see Table 14). Most other countries in the Region have reported mental health activities in general health statistics. Two countries have not compiled a mental health report in the past 2 years, and one country did not submit a response to this item.
13. Suicide prevention Globally, suicide was the cause of 804 000 7 deaths in 2012. Suicide prevention is a priority, and Target 3.2 of the Comprehensive Mental Health Action Plan aims for a 10% reduction in suicides by 2020. The Atlas 2014 asked countries to report on suicide rates and on their suicide prevention strategies. Three countries in the Eastern Mediterranean Region reported that they have developed national suicide prevention strategies: Islamic Republic of Iran, Palestine and Tunisia. 7
Comparison of reporting of core mental health indicator set in the Eastern Mediterranean Region with the rest of the world The Eastern Mediterranean Region compares favourably with other regions for reporting of mental health data (see Figure 41). The Region ranks second for specific mental health reports for public and private sectors, and for public sector only. A smaller percentage of countries of the Region have not compiled mental health data in the past 2 years than in all but one other WHO region.
Preventing suicide: a global imperative.
32
Discussion
Table 14. Availability of mental health activity reporting in the past 2 years Availability/status of mental health reporting No mental health data have been compiled in a report for policy, planning or management purposes in the past 2 years Mental health data have been compiled for general health statistics in the past 2 years, but not in a specific mental health report A specific report focusing on mental health activities in the public sector only has been published by the health department or any other responsible government unit in the past 2 years A specific report focusing on mental health activities in the public and private sectors has been published by the health department or any other responsible government unit in the past 2 years Number of countries 2 8 8 % 10% 38% 38%
3
14%
Discussion All 22 countries in the Eastern Mediterranean Region submitted data for the Mental health atlas 2014. Items such as policy, legislation and stakeholder involvement were answered comprehensively by all countries. However, other items, particularly those pertaining to finances, service use and suicide, were answered by only a minority of countries. This has severely constrained the scope of analysis of the Regional review, but also illustrates of significant issues relating to budgetary and
service planning and information systems, which will be discussed further. The Atlas survey has highlighted the scope for development of leadership and governance in mental health, and this is indicated by the total absence of fully implemented mental health policies and near total absence of fully implemented mental health legislation. Compared with other WHO regions, the Eastern Mediterranean Region has been the most active in recently publishing and reviewing mental health policies and plans. However, where present, mental health
46 39 Percentage of countries in each WHO region
40
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38 38 30
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38 30 21 31
42
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20 12 3 14 14
18 10 4
10
No mental health data compiled in past two years
Mental health data compiled only for general health statistics AMR EMR EUR
Mental health specific data compiled in past two years for public sectors SEAR WPR Global
Mental health specific data compiled in past two years for public and private sectors
AFR
Reporting of mental health data
Figure 41. Reporting of mental health data in the past 2 years, by WHO region
33
Mental health atlas 2014
policies are only partially implemented and many require revision to bring them in line with internationally agreed human rights instruments. The lack of effective policies and governance providing a framework for development has also affected stakeholder involvement, which is very underdeveloped in the Region. The strengthening of leadership and governance in the Region with involvement of stakeholders would be important steps in influencing and catalysing the development of mental health resources in order to address the increasing burden of mental illness. The Atlas 2014 survey also shows that the majority of countries could not provide specific data on mental health spending, and this suggests a lack of a specific budget for mental health. In the absence of a current specific mental health budget it is difficult to formulate a clear framework for mental health resources development. Clarification of budgets and budgetary planning linked with development is a clear opportunity for a focused strengthening of mental health leadership and governance. The overall trend in the Region of increasing specialist mental health staff, such as nurses, psychiatrists and psychologists, is encouraging. However, the mental health workforce has decreased in some countries. The fall in psychiatrists per 100 000 in group 2 countries, compared with an increase in group 1 countries, suggests that sociopolitical and economic factors may be a factor influencing the availability and mobility of mental health resources within the Region. Key factors to consider in mental health workforce planning are the retention and attraction of skilled mental health professionals. Alongside consideration of the specialist mental health workforce, the general health workforce is accessible to far greater numbers of people with common mental health problems. The ability of primary care to respond and provide
cost-effective interventions for mental health problems can be strengthened by mental health training for primary care staff. The Atlas 2014 findings indicate that only a small minority of primary care staff (2.7% of physicians and 1.6% of nurses and midwives) have received at least 2 days of training in mental health in the past 2 years. These figures are similar to the global medians. This is therefore an area of potential development to address the goals of the Comprehensive Mental Health Action Plan. There is a large variation of mental health facilities in countries across the Region, which is at least in part associated with the availability of resources and political stability (for example: progressively fewer psychiatric beds per 100 000 population comparing group 1 to group 2 and group 3 countries, and fewer nurses and psychiatrists per 100 000 population in group 2 than group 1 countries). Nevertheless there are examples of countries with relatively meagre resources or that are dealing with crises or political unrest where meaningful progress towards the goals of the Comprehensive Mental Health Action Plan have already been made, for example: increased availability of psychiatric beds in community residential facilities in Pakistan; mental health promotion and prevention programmes in Djibouti and Pakistan; and reduced length of inpatient stays in Palestine. Compared with other WHO regions, the Eastern Mediterranean Region has relatively low levels of psychiatric beds, particularly in general hospitals and community residential facilities, and the distribution of psychiatric beds between mental hospitals, general hospitals and community residential facilities in the Region has not changed between 2011 and 2014, which at first sight suggests that there may be inertia in the provision of inpatient services. However, the median total number of psychiatric beds per 100 000
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Discussion
population fell between 2011 and 2014, and there has also been a reduction in the median number of outpatient facilities per 100 000 population. These trends may represent the lack of sustainable policies for maintaining mental health infrastructure or possibly even disinvesting in mental health infrastructure. Unfortunately financial data are not available to confirm or refute this hypothesis. However, another possible explanation for this trend is that there is more focused use of current resources and thus restructuring of current infrastructure to create fewer but more efficient units to provide for mental health care. This has some support in that there has been a more than four-fold increase in the median number of outpatient visits in 2014 as compared to 2011. The increase in outpatient visits may also be partially explained if care has shifted from to the community following the reduction in psychiatric inpatient beds. This may represent changes in cultural attitudes and possibly destigmatization of mental disorders, which will have a long-term impact on healthcare consumption behaviour. Careful consideration may need to be taken to ensure that current policies that influence development of mental health infrastructure will be in line with meeting the demand for mental health consumption. Further research may also be beneficial into the cultural changes that have increased the consumption of mental health outpatient services to better help inform changes to existing policies and help with longer-term mental health resource development planning. There is a large range in the numbers of national mental health promotion and prevention programmes, and unlike the treatment services, this appears to be irrespective of a country’s development or wealth as represented by the health system grouping. This suggests that there is capacity for promotion and prevention programmes in
all countries. Yet more than half of countries in the Region have not yet started to address mental health promotion and prevention programmes, and for those countries this represents an important opportunity. Although almost all countries reported that they have captured and reported on mental health data over the past 2 years, this regional analysis indicates that there are significant and widespread gaps in the data collection and highlights that current information systems may not be in-line with target indicators of the Comprehensive Mental Health Action Plan and Mental health atlas. The failure of many countries to report on service coverage, length of hospital stay, follow-up of patients after discharge from inpatient care and provision of social support in the community not only highlights the need for improved information systems, but also suggests a lack of leadership and governance structures with service user and carer participation for the transition of care to community settings. Suicide is poorly reported across the Region, and the majority of countries do not have any suicide prevention strategies in place. This presents an important opportunity for the development of prevention strategies respecting the social, religious and cultural aspects of suicide and suicide reporting in the countries of the Region.
Baseline comparison with the targets of the Comprehensive Mental Health Action Plan 2015–20 The Mental health atlas 2014 was revised from previous versions of the Atlas to focus on the targets and indicators identified in the Comprehensive Mental Health Action Plan. In the final section of this review, the extent to which the Eastern Mediterranean Region measures up in 2014 against the six global targets for 2020 is examined.
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Mental health atlas 2014
Global Target 1.1. 80% of countries will have developed or updated their policy/plan for mental health in line with international and regional human rights instruments (by 2020). Although 55% of countries of the Region have updated their mental health policies in the past 5 years, many are not compliant with some or all international human rights instruments. In 2014, seven countries of the Region, or 32%, are compliant with all five of the five measured components of human rights and therefore meet the Action Plan target; although no country of the Region claims that these policies are as yet fully implemented. If this target is to be achieved in the Region, policies need to be updated in line with human rights instruments in at least 11 more countries by 2020; and strong leadership is required to ensure that these policies are properly resourced and implemented. Global Target 1.2. 50% of countries will have developed or updated their law for mental health in line with international and regional human rights instruments (by 2020). 73% of countries of the Region have mental health legislation (either stand-alone or integrated into other legislation), but as with policy this is often not compliant with some or all international human rights instruments. In 2014, six countries of the Region, or 27%, are compliant with all five measured components of human rights instruments and therefore meet the Action Plan target; although none of these country states that these laws are fully implemented (five of the six state the legislation is available but not implemented, one states it is available and partially implemented). If this target is to be achieved in the Region, mental health legislation in line with human rights instruments needs to be updated and enacted in five more countries of the Region, along with appropriate governance to ensure that mental health laws are implemented in all countries.
Global Target 2. Service coverage for severe mental disorders will have increased by 20% (by 2020). In order to monitor and assess this indicator a current baseline of service coverage needs to be established. Our current information does not properly establish this baseline. First, the denominator for calculating coverage is the total population at risk, rather than the total population in need. Secondly, the reporting of numbers of people with severe mental disorders treated is available only for 13 countries at the level of the mental hospital and nine at general hospital and eight at mental health outpatient levels. If the treated prevalence in mental health outpatient facilities, currently at the level of 1158 per 100 000 population (based on eight countries) is to increase by 20% by 2020, then the target is 1390 per 100 000 population. Global Target 3.1. 80% of countries will have at least two functioning national, multisectoral mental health promotion and prevention programmes (by 2020). According to responses to Atlas 2014, nine or 41% of countries of the Region have two or more functioning programmes. Among the other 13 countries, only two have one programme, the remaining 11 have no functioning national promotion or prevention programmes. To meet the target by 2020, the nine countries with two or more programmes must continue to have eligible programmes, and a further nine countries of the Region must establish two or more national promotion or prevention programmes. Global Target 3.2. The rate of suicide in countries will be reduced by 10% (by 2020). This target requires a current baseline against which to measure progress in 2020. Only five countries (23%) reported rates of suicide in the Mental health atlas 2014 survey, with a median of 1.6 suicides per 100 000 per year. A reduction by 10% suggests a target of less
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Discussion
than 1.44 suicides per 100 000 per year. However the currently reported rates may underestimate the true suicide rate due to possible underreporting for social, religious and cultural reasons. There is an urgent need to work towards establishing accurate suicide reporting in countries of the Region. Global Target 4. 80% of countries will be routinely collecting and reporting at least a core set of mental health indicators every 2 years through their national health and social information systems (by 2020). Although 19 countries of the Region have produced reports on mental health data (either dedicated reports or reports on mental health in general health statistics), it is clear from the responses to the Atlas questionnaire that the extent of mental health information is limited in most countries of the Region. Only one country reported on all the indicators, and for several sections that country reported from a
region rather than the whole country. With the regional framework for implementation of the Comprehensive Mental Health Action Plan, the Regional Office for the Eastern Mediterranean has provided a core set of indicators that countries can incorporate into their health management and other information systems or collect by periodic surveys in order to monitor progress towards the targets of the Action Plan. The current status of the Region in relation to the 2020 targets of the Comprehensive Mental Health Action Plan is summarized in Table 15. With each biennial Atlas survey the percentage progress towards achieving the 2020 target should increase towards 100% by 2020. In order to progress from the current situation to achieve the global targets and goals of the Comprehensive Mental Health Action Plan, the Region needs to commit to early and sustained mental health development over
Table 15. Extent to which the global targets of the Comprehensive Mental Health Action Plan have been met at baseline in 2014 Targets set out in the Comprehensive Mental Status of Eastern Mediterranean Health Action Plan (2013–2020) Region in Atlas 2014 to be achieved by 2020 Policy: 80% of countries will have developed or updated their policy/plan for mental health in line with international and regional human rights instruments. Seven or 32% of countries have contemporary mental health policies compliant with international human rights instruments Percentage progress towards achieving the 2020 target 40%
Legislation: 50% of countries will have developed Six or 27% of countries or updated their law for mental health in line with contemporary mental health international and regional human rights instruments. legislation compliant with international human rights instruments Coverage: service coverage for severe mental disorders will have increased by 20%. 3.1. Prevention and promotion: 80% of countries will have at least two functioning national, multisectoral mental health promotion and prevention programmes. 3.2. Suicide: the rate of suicide In countries will be reduced by 10%. Treated prevalence in mental health outpatient facilities, of 1158 per 100 000 population Nine or 41% of countries have two or more functioning programmes
54%
Atlas 2014 establishes baseline
51%
Median of 1.6 suicides per 100 000 per year based on five reporting countries.
Atlas 2014 establishes baseline, but this is inadequate due to low response rate and underreporting. 6%
Information: 80% of countries will be routinely One or 5% of countries reported on collecting and reporting at least a core set of all the indicators in Atlas 2014, mental health indicators every 2 years through their national health and social Information systems.
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Mental health atlas 2014
the next 6 years. The Eastern Mediterranean regional framework for scaling up action on mental health8 along with its accompanying briefing documents and resources provides guidance on how this can be achieved. Success will depend on prompt establishment of strong leadership for mental health in each country empowered with sufficient information and effective governance of resources to plan and deliver. Key partnerships need to be forged, none more important than service user and carer participation. The mental health atlas survey, with Region-specific modifications and interim indicators, will be repeated every
2 years to assist in monitoring progress. WHO will also provide technical advice and support to countries as they work towards implementation of the regional framework. Countries who succeed in achieving these targets will be making a major contribution to their populations in achieving the overall goal of the Comprehensive Mental Health Action Plan to “promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability for persons with mental disorders”.
8
WHO Regional Committee for the Eastern Mediterranean resolution EM/RC62/R.5 scaling up mental health care: a framework for action. Cairo: WHO Regional Office for the Eastern Mediterranean; 2015 (http://applications.emro.who.int/docs/ RC62_Resolutions_2015_R5_16582_EN.pdf?ua=1, accessed 4 February 2016).
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Mental disorders have a profound effect on individuals, their families and society. The Mental health atlas 2014 provides up-to-date information on the availability of mental health services and resources across the WHO Eastern Mediterranean Region. This is the first time that all the countries of the Region have participated and contributed to this exercise. The results provide an invaluable resource that will assist stakeholders to identify gaps in current provision and inform decisions around increasing resources to scale up services for mental health, and support the monitoring of progress towards global and regional targets.
44EMRO Technical Publications Series Mental health atlas 2014 Resources for mental health in the Eastern Mediterranean Region
44EMRO Technical Publications Series Mental health atlas 2014 Resources for mental health in the Eastern Mediterranean Region WHO Library Cataloguing in Publication Data World Health Organization. Regional Office for the Eastern Mediterranean Mental health atlas 2014: resources for mental health in the Eastern Mediterranean Region / World Health Organization. Regional Office for the Eastern Mediterranean p. .- (EMRO Technical Publications Series; 44) ISBN: 978-92-9274-705-3 ISBN: 978-92-9274-706-0 (online) ISSN: 1020-0428 1. Mental Health Services - statistics & numerical data 2. Health Policy 3. Health Resources - statistics & numerical data 4. Health Care Rationing I. Title II. Regional Office for the Eastern Mediterranean III. Series (NLM Classification: WM 16) This publication was originally published under ISBN: 978-92-9022-117-3, 978-92-9022-118-0 © World Health Organization 2016 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. Layout by Punto Grafico. Printing by WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. Contents Executive summary ...................................................................................... 7 Introduction ................................................................................................... 7 Methods .......................................................................................................... 9 Results .......................................................................................................... 10 1. Mental health policy ........................................................................................................................... 10 2. Mental health legislation .................................................................................................................... 13 3. Stakeholder involvement ................................................................................................................... 17 4. Government mental health spending ............................................................................................. 18 5. Mental health workforce ................................................................................................................... 21 6. Mental health training in primary care ........................................................................................... 24 7. Service availability ............................................................................................................................... 26 8. Service coverage for severe mental disorders ............................................................................. 29 9. Inpatient care ....................................................................................................................................... 30 10. Continuity of care after discharge .................................................................................................. 31 11. Social support ...................................................................................................................................... 32 12. Mental health promotion and prevention ..................................................................................... 32 13. Suicide prevention .............................................................................................................................. 33 14. Core mental health indicator set .................................................................................................... 34 Discussion..................................................................................................... 35 Baseline comparison with the targets of the Comprehensive Mental Health Action Plan 2015–20 ..................................................................................................... 37
5Executive summary Executive summary The first assessment of available mental health resources in WHO Member States was carried out in 2001.1 Updates were published for 2005 and 2011.2,3 The Mental health atlas 2014 provides up-to-date information on the availability of mental health services and resources across the Eastern Mediterranean Region. This information was obtained via a questionnaire sent to designated focal points in each WHO Member State. Findings relating to key indicators can be used as a baseline against which to measure progress towards meeting the goals of the Comprehensive Mental Health Action Plan.4 Comparisons have also been made with the rest of the world and earlier mental health atlas reports. The latest key findings are presented in the Box below. Introduction The WHO Atlas of mental health resources was first produced in 2001 and was updated in 2005 and 2011. It is an important resource on global information on mental health and a tool for developing and planning mental health services. The Comprehensive Mental Health Action Plan 2013–2020 was adopted by the 66th World Health Assembly in May 2013. The action plan sets out goals and objectives to be achieved by 2020. In order to monitor progress in achieving these targets and to monitor other critical aspects of mental health system development, a set of core mental health indicators was developed (see Table 1). The core mental health indicators for the action plan were incorporated into the Atlas Key findings Regional reporting on core mental health indicators • All 22 countries of the Region at least partially completed the atlas questionnaire, although many countries did not fully complete the sections on financing, workforce, service use and suicide. Mental health governance • 55% of countries of the Region have updated their mental health policies or plans in the past 5 years, but only 32% of countries of the Region have mental health policies that are fully compliant with international human rights instruments. 73% of countries of the Region have mental health legislation, but only 27% have mental health legislation that is fully compliant with international human rights instruments. Implementation of mental health legislation is weak. Persons with mental disorders and family members are rarely involved in the formulation and implementation of mental health policies, laws and services. Financial and human resources for mental health • Levels of public expenditures on mental health are not known for most countries of the Region, suggesting that specific budgets may not be set aside for mental health services. Spending is very low (less than US$ 2, per capita), and the majority of funding goes to inpatient care, especially mental hospitals. • The median number of mental health workers in the countries of the Region is half that reported in the rest of the world, and there is extreme variation with greater density of mental health workers in health system group 1 countries. Mental health service availability and uptake • The median number of mental health beds per 100 000 population ranges from 1.7 in health system group 3 countries, through 6.4 in group 2 countries, up to 11.3 in group 1 countries. This compares with over 50 in high-income countries in the rest of the world; median rates of day care and outpatient facilities indicate they are relatively underdeveloped compared with the rest of the world. Mental health promotion and prevention • 41% of countries of the Region have at least two functioning mental health promotion and prevention programmes, a similar percentage to the rest of the world. Only 14% of countries of the Region have developed national suicide prevention strategies. Mental health information • 52% of countries of the Region regularly compile mental health–specific data covering at least the public sector. Vital reporting systems are poorly developed, and there are issues of underreporting of suicide. Less than 25% of countries were able to report on the number of suicides. 1 Atlas: mental health resources in the world 2001. Geneva: WHO; 2001. 2 Mental health atlas 2005. Geneva: WHO; 2005. 3 Mental health atlas 2011. Geneva: WHO; 2011. 4 Mental health action plan 2013–2020. Geneva: WHO; 2013. 6Mental health atlas 2014 2014. Between 2014 and 2020, a mental health atlas survey will be carried out every 2 years so that progress towards meeting the targets of the Action Plan can be monitored. The WHO Regional Office for the Eastern Mediterranean has developed a framework for implementation of the action plan. The framework incorporated intermediate indicators to monitor progress towards the global goals and objectives. It is planned that these intermediate indicators will be incorporated into the Mental health atlas in the Eastern Mediterranean until 2020. The Comprehensive Mental Health Action Plan 2013–2020 contains six indicators for assessing progress towards agreed objectives and targets (see Table 1). The WHO secretariat was requested to identify additional mental health indicators for Member States to report on (see Table 1, Service development indicators). Together, these form the core set of mental health indicators. The final set of Table 1. Core mental health indicators, by action plan objective and target Action plan objectives Action plan targets Action plan indicators Service development indicators Objective 1. To strengthen effective leadership and governance for mental health Target 1.1. 80% of countries will have developed or updated their policies or plans for mental health in line with international and regional human rights instruments (by 2020) Existence of a national policy/ plan for mental health that is in line with international and regional human rights instruments Financial resources. Government health expenditure on mental health Human resources. Number of mental health workers Capacity-building. Number and proportion of primary care staff trained in mental health Target 1.2. 50% of countries will have developed or updated their law for mental health in line with international and regional human rights instruments (by 2020) Existence of a national law covering mental health that is in line with international and regional human rights instruments Objective 2. To provide comprehensive, integrated and responsive mental health and social care services in community- based settings Target 2. Service coverage for severe mental disorders will have increased by 20% (by 2020) Number and proportion of persons with a severe mental disorder who received mental health care in the past year Stakeholder involvement. Participation of associations of persons with mental disorders and family members in service planning and development Service availability. Number of mental health care facilities at different levels of service delivery Objective 3. To implement strategies for promotion and prevention in mental health Target 3.1. 80% of countries will have at least two functioning national, multisectoral mental health promotion and prevention programmes (by 2020) Functioning programmes of multisectoral mental health promotion and prevention in existence Inpatient care. Number and proportion of admissions for severe mental disorders to inpatient mental health facilities that a) exceed one year and b) are involuntary Target 3.2. The rate of suicide in countries will be reduced by 10% (by 2020) Number of suicides per year Service continuity. Number of persons with a severe mental disorder discharged from a mental or general hospital in the past year who were followed up within one month by community-based health services Social support. Number of persons with a severe mental disorder who receive disability payments or income support Objective 4. To strengthen information systems, evidence and research for mental health Target 4. 80% of countries will be routinely collecting and reporting at least a core set of mental health indicators every 2 years through their national health and social information systems (by 2020) Core set of mental health indicators routinely collected and reported every 2 years 7Executive summary indicators used in Atlas 2014 were formulated and agreed following consultation with the regions and field-testing. Methods The Mental health atlas 2014 project was carried out in three stages. In the first stage, the questionnaire was developed in consultation with Member States and regional offices. The final questionnaire was translated into three official UN languages (French, Russian and Spanish), and a completion guide was prepared, which explained terminology and definitions to ensure standardized completion of the questionnaire. During the second stage the questionnaire was disseminated to a focal point, appointed by the ministry of health in each Member State. The focal point completed the questionnaire incorporating information provided by experts in the field and with guidance and support provided by staff at WHO headquarters and regional offices. In the third stage, the completed questionnaires were submitted and checked for inconsistencies or incomplete responses. Focal points were contacted again during clarification and checking of the responses to generate the highest quality data. All countries in the Eastern Mediterranean Region were invited to complete the Mental health atlas 2014 (see Table 2). Data were analysed for the Eastern Mediterranean Region, and comparisons made with global data, and where appropriate comparisons were made with data from Mental health atlas 2011. Rates per 100 000 population were calculated using UN population estimates for 2013. Monetary values where available were standardized to US$, base year 2014. Within the Region comparisons were made based on the regional health system groups. The Regional Office for the Eastern Mediterranean has grouped countries based on broadly similar Table 2. Countries that completed the Mental health atlas 2014 questionnaire Afghanistan Oman Bahrain Palestine Djibouti Pakistan Egypt Qatar Iran (Islamic Republic of) Saudi Arabia Iraq Somalia Jordan Sudan Kuwait Syrian Arab Republic Lebanon Tunisia Libya United Arab Emirates Morocco Yemen Table 3. Regional health system groups Group 1 Group 2 Group 3 Countries where socioeconomic development has progressed considerably over recent decades, supported by high income Largely middle-income countries which have developed extensive public health service delivery infrastructure but face resource constraints Countries which face major constraints in improving population health outcomes as a result of lack of resources for health, political instability and other complex development challenges Bahrain Kuwait Oman Qatar Saudi Arabia United Arab Emirates Egypt, Iran (Islamic Republic of) Iraq Jordan Lebanon Libya Morocco Palestine Syrian Arab Republic Tunisia Afghanistan Djibouti Pakistan Somalia Sudan Yemen 8Mental health atlas 2014 characteristics in terms of their population health outcomes, health system performance and level of health expenditure (see Table 3). The data reported in this regional review differ in some respect from those in the global Mental health atlas 2014. This review includes data for Palestine, and some data excluded from the global report has been included in this report as it is of regional relevance. Results All 22 countries of the Region completed the Mental health atlas 2014 questionnaire, compared with a response rate of 87% from the rest of the world. All countries of the Region reported on some indicators, such as those relating to mental health policy and law. However, for some items the country response rates were very low (e.g. six or fewer countries provided data), for example: mental health spending, service coverage, continuity of care, social support and suicide rates. It is not possible to make meaningful regional analyses with such limited data. Therefore, only a cursory summary of data on these items is included. 1. Mental health policy The first objective of the Comprehensive Mental Health Action Plan is to strengthen leadership and governance for mental health. Leadership and governance are expressed through mental health policy, legislation and provision of resources. Mental health policy is a statement of the values, principles, objectives and areas for action to improve mental health. These may be stand-alone or may be integrated into other general health or disability policies or plans. For the purposes of the Mental health atlas 2014, a policy is considered valid only if it has been approved/published by the ministry of health or parliament. Countries were asked about the presence of a stand-alone or integrated mental health policy and the year of its latest revision. Most countries (68%) have a stand-alone mental health policy (see Figure 1). Two countries (9%) have mental health integrated into other general health or disability policies or plans. Five countries (23%) do not have a mental health policy or plan. Among countries with a stand-alone mental health policy, 12 (55% of all countries) were published or revised within the previous 5 years. The remaining three were all published within the past 12 years. Figure 1. Number of countries with an approved/ published mental health policy Figure 2. Current status of policy/plans for mental health 5 years 2 years 15 years Stand-alone mental health policy Integrated mental health policy No mental health policy 0 4 4 1 17 0 8 12 16 20 No t d ev elo pe d/ no t a va ila ble Av ail ab le an d f ull y im ple me nte d Av ail ab le bu t n ot im ple me nte d Av ail ab le an d pa rti all y im ple me nte d Availability of policy/plans for mental health N um be r of c ou nt ri es 9Mental health policy Countries were asked to comment on the current status of implementation of a mental health policy (including both stand-alone and integrated policies). Most (77%) reported that a policy was available and partially implemented (see Figure 2). None was fully implemented. One had a policy available but not yet implemented, and four did not have an available mental health policy. Countries were asked if their policies are compliant with international human rights instruments. Most countries’ policies promote community-based and integrated services and explicitly respect human rights (see Figure 3). More than half promote a full range of services to enable people to live independently. However, less than half promote a recovery approach to mental health care and participation in decision-making processes. Progress in presence of a mental health policy or plan between 2011 and 2014 Across the whole Eastern Mediterranean Region and within each health system group, there was little change in the percentage of countries with a stand-alone mental health policy between 2011 and 2014 (see Table 4). In 2014, 11 countries had a mental health policy or plan updated from 2011 onwards, five countries have updated policies/plans in line with all five items of the human rights instruments. Figure 3. Compliance of mental health policy with human rights instruments (% of all countries in the Eastern Mediterranean Region) 0 20 40 60 80 100 77 77 55 45 36 Aspects of international human rights instruments Pe rc en ta ge o f c ou nt ri es th at a re c om pl ia nt Promotes community- based and integrated services Explicitly respects human rights Promotes a full range of services to enable people to live independently Promotes a recovery approach to mental health care Promotes participation in decision making processes Table 4. Countries with stand-alone mental health policies in 2011 and 2014, by regional health system group Group Countries with mental health policy or plan (% of all reporting countriesa) 2011 2014 Eastern Mediterranean Region 16 (80%) 17 (77.3%) Health system group 1 6 (100%) 5 (83.3%) Health system group 2 7 (77.8%) 7 (70%) Health system group 3 3 (60%) 4 (66.7%) a The total number of countries reporting these data differed between 2011 and 2014, and hence the percentages for the 2 years have different denominators. 10 Mental health atlas 2014 Comparison of mental health policy in the Eastern Mediterranean Region with the rest of the world Globally, 77% of countries have stand-alone mental health policies. The percentage of countries with stand-alone policies in the Eastern Mediterranean Region (68%) is lower than the global figure. The percentage of countries with mental health policies published or revised in the past 5 years in the Region (55%) is greater than the global rate of 47% and is among the highest reported by any WHO region5 (see Figure 4). The percentage of countries in which mental health policy is either fully or partially implemented in the Region (77%) is similar to the corresponding global figure of 76%, and the Eastern Mediterranean Region lies in the middle range of WHO regions (see Figure 5). However, when global comparisons are made Figure 4. Percentage of countries in each WHO region that have published or revised their mental health policy in the past 5 years 10 0 20 30 40 50 60 42 43 5655 30 46 36 AFR AMR EMR EUR SEAR WPR Pe rc en ta ge w ith m en ta l h ea lth p ol ic y pu bl is he d or r ev is ed in t he p as t fiv e ye ar s WHO region 5 The WHO regions are: Africa (AFR), Americas (AMR), South-East Asia (SEAR), Europe (EUR), Eastern Mediterranean (EMR) and Western Pacific (WPR). Figure 5. Percentage of countries in each WHO region that have partially or fully implemented their mental health policy 55 84 89 77 90 66 36 AFR AMR EMR EUR SEAR WPR Pe rc en ta ge o f c ou nt ri es t ha t ha ve p ar tia lly o r fu lly im pl em en te d th ei r m en ta l h ea lth p ol ic y WHO region 100 90 80 70 60 50 40 30 20 10 0 11 Mental health legislation of full implementation rates, the Region has the lowest rate of 0% (compared with highs of 28% in the European Region and 30% in South-East Asian Region). The Eastern Mediterranean Region compares less favourably with the rest of the world for compliance of mental health policies with international human rights: 45% of countries of the Region are compliant with more than three standards of international human rights, compared with 72% of all world countries. Seven (32%) countries of the Region are compliant with all five human rights standards, compared with 56% of all world countries (see Figure 6). Compared with other WHO regions, the Eastern Mediterranean Region has the lowest compliance with international human rights. 2. Mental health legislation Mental health legislation is legislation specifically related to mental health that protects the civil and human rights of people with mental disorders and addresses treatment facilities, personnel, professional training and service structure. Mental health law may be stand-alone, or may be integrated into other general health or disability laws. Countries were asked about the presence of stand-alone or integrated mental health legislation and the year of its latest revision. Most countries have a stand-alone mental health law (see Figure 7). Four countries have mental health integrated into other general health or disability laws. Five countries do not have a mental health law. Figure 6. Percentage of countries in each WHO region that have mental health policies that are compliant with all five standards of international human rights 41 63 74 32 44 59 36 AFR AMR EMR EUR SEAR WPR Pe rc en ta ge w ith m en ta l h ea lth p ol ic y co m pl ia nt w ith a ll fiv e st an da rd s of in te rn at on al h um an r ig ht s WHO region 80 70 60 50 40 30 20 10 0 Figure 7. Number of countries with mental health legislation Stand-alone mental health law Integrated mental health law No mental health law Stand-alone law soon to be enacted 5 4 12 1 12 Mental health atlas 2014 Among countries with a stand-alone mental health law who provided data on year of enactment, five were enacted/revised within the past 5 years (see Figure 8). The remaining four were enacted more than 10 years ago, including one that dates back to 1959. One further country has stand-alone legislation that is about to be enacted. Countries were asked to indicate the current status of implementation of their mental health legislation (including both stand-alone and integrated laws). Two (9%) reported that their mental health laws are fully implemented (see Figure 9). In 18% of countries of the Region, mental health legislation is not developed/ available and in a further 36% of countries it is available but not implemented. 59% of countries indicated that their mental health legislation is compliant with international human rights instruments in that they promote rights to exercise capacity and Figure 8. Decade that the mental health law was enacted Figure 9. Status of the law covering mental health Figure 10. Compliance of mental health law with international human rights instruments (% of all countries of the Region) 0 20 40 60 80 100 45 59 59 59 45 Aspects of international human rights instruments Pe rc en ta ge o f c ou nt ri es Promotes transition to mental health services in the community Promotes rights to exercise capacity and nominate a trusted person to support them Promotes alternatives to coercive practice Provides to protect rights and file appeals and complaints to independent legal body Provides for regular inspection of human rights conditions by an independent body 1 1 5 2 20 10 s N um be r of c ou nt ri es 6 5 4 3 2 1 0 19 50 s 19 60 s 19 70 s 19 80 s 19 90 s 20 00 s 4 8 8 2N um be r of c ou nt ri es 9 8 7 6 5 4 3 2 1 0 Availability of laws covering mental health No t d ev elo pe d/ no t a va ila ble Av ail ab le an d f ull y im ple me nte d Av ail ab le bu t n ot im ple me nte d Av ail ab le an d pa rti all y im ple me nte d 13 Mental health legislation nominate a trusted person to support them; promote alternatives to coercive practice; and provide to protect rights and provide appeals and complaints to independent legal bodies (see Figure 10). Just under half of the countries in the Region indicated that their legislation promotes transition to mental health services in the community and provides for regular inspection of human rights conditions by an independent body. Progress in the presence of stand-alone mental health legislation between 2011 and 2014 Across the whole Eastern Mediterranean Region and within each health system group, there was little change in the percentage of countries with stand-alone mental health legislation between 2011 and 2014 (see Table 5). Six countries of the Region have developed or updated their mental health legislation between 2011 and 2014. Comparison of mental health legislation in the Eastern Mediterranean Region with the rest of the world Globally, 63% of countries have stand-alone mental health legislation. The percentage of countries with stand-alone legislation in the Eastern Mediterranean Region (55%) is slightly lower than the global figure. The percentage of countries with mental health legislation published or revised in the past 5 years in the Region (23%) is greater than the corresponding global rate of 18% and is the third highest among WHO regions (see Figure 11). Table 5. Countries of the Region with stand-alone mental health legislation in 2011 and 2014, by regional health system group Group Presence of stand-alone mental health legislation (% of all countries) 2011 2014 Eastern Mediterranean Region 11 (55%) 12 (54.5%) Health system group 1 2 (33.3%) 2 (33.3%) Health system group 2 7 (77.8%) 7 (70%) Health system group 3 2 (40%) 2 (33.3%) Figure 11. Percentage of countries in each WHO region that have passed or revised their mental health legislation in the past 5 years 3 7 25 23 20 38 36 AFR AMR EMR EUR SEAR WPR Pe rc en ta ge w ith m en ta l h ea lth le gi sla tio n pu bl ish ed o r re vi se d in th e pa st 5 y ea rs WHO region 40 35 30 25 20 15 10 5 0 14 Mental health atlas 2014 The percentage of countries in which mental health legislation is either fully or partially implemented in the Region (45%) is lower than the corresponding global figure of 69% and is lower than other WHO regions (see Figure 12). Eleven or 55% of reporting countries of the Region are compliant with more than three standards of international human rights, compared with 61% of all world countries. Six or 25% of reporting countries of the Region are compliant with all five standards of international human rights, compared with 42% of all world countries. The Eastern Mediterranean Region ranks fifth (out of six regions) most compliant with international human rights (see Figure 13). Figure 12. Percentage of countries in each WHO region that have partially or fully implemented mental health legislation Figure 13. Percentage of reporting countries in each WHO region that have mental health legislation which is compliant with all five standards of international human rights 53 76 87 45 50 78 36 AFR AMR EMR EUR SEAR WPR Pe rc en ta ge o f c ou nt rie s th at h av e pa rt ia lly o r fu lly im pl em en te d th ei r m en ta l h ea lth le gi sla tio n WHO region 100 90 80 70 60 50 40 30 20 10 0 31 33 54 25 22 57 36 AFR AMR EMR EUR SEAR WPRP er ce nt ag e w ith m en ta l h ea lth le gi sla tio n co m pl ia nt w ith a ll fiv e st an da rd s of in te rn at on al h um an r ig ht s WHO region 60 50 40 30 20 10 0 15 Stakeholder involvement 3. Stakeholder involvement Countries were asked to indicate the level of involvement of associations of persons with mental disorders and family members in the formulation and implementation of mental health policies, laws and services at a national level in the past 2 years. This was done on a three-point scale (not implemented; partially implemented; fully implemented) for five domains: information, policy, early involvement, participation and resources (see Box 1). In all domains, most countries reported that measures are not implemented (see Figure 14). In about one-quarter of countries, measures were partially implemented. Full implementation was rarely reported; in only one country for the domains of information, policy and resources; and in no countries for early involvement and participation. Comparison of stakeholder involvement in the Eastern Mediterranean Region with the rest of the world Compared with the rest of the world, the Eastern Mediterranean Region has a lower level of involvement of associations of service users and their families, and this is evident for partial or full implementation in all five stakeholder involvement domains (see Figure 15). When compared with other WHO regions, the Eastern Mediterranean Region ranked fifth (of six regions) for the domain of policy, and ranked sixth (of six regions) for information, early involvement, participation and resources. Stakeholder involvement is an aspect of mental health services that is particularly underdeveloped in almost all countries of the Region, and therefore there are opportunities to develop partnerships to catalyse and influence change in the planning and delivery of mental health services. Box 1. Domains of involvement of associations of persons with mental disorders and family members in the formulation and implementation of mental health policies, laws and services 1. Information: ministry of health gathers and disseminates information about organizations of persons with mental and psychosocial disabilities and of families and carers. 2. Policy: ministry of health has developed and published a formal policy on the participation of persons with mental and psychosocial disabilities in the formulation and implementation of mental health policies, plans, legislation and services. 3. Early involvement: persons with mental and psychosocial disabilities, as well as families and carers, are involved from the beginning of the formulation and implementation of mental health policies and laws, and given adequate notice. 4. Participation: ministry of health systematically involves persons with mental and psychosocial disabilities in planning, policy, service development and evaluation: the majority of committees and subcommittees developing the above areas have representation from an organization of persons with mental and psychosocial disabilities or at least one person with a mental and psychosocial disability. 5. Resources: ministry of health reimburses costs of participation of persons with mental and psychosocial disabilities and provides resources to allow participation (physical location, transport, remuneration or reimbursement of expenses, interpreters, attendant carers and meeting support personnel). Figure 14. Implementation of stakeholder involvement 6 Pe rc en ta ge o f c ou nt ri es 31 31 17 4 1616 6 16 3 24 20 16 12 8 4 0 Aspects of implementation of stakeholder involvement Inf or ma tio n Po lic y Ea rly in vo lve me nt Pa rti cip ati on Re so ur ce s Fully implemented Partially implemented Not implemented 16 Mental health atlas 2014 4. Government mental health spending The government is the main source of mental health care and treatment funding in most countries in the Eastern Mediterranean Region (see Figure 16), which is similar to the sources of funding found in the rest of the world. Less than half of the countries reported on the annual government spending on the various component settings of their mental health services (see Figure 17). Annual spending on mental hospitals was reported by six (27%) countries. Spending on other components was reported by fewer countries. That countries are unable to provide a breakdown of spending suggests that specific budgets may not be set aside for mental health services. The small number of countries able to provide costing data limits the use of regional analysis for most components of the mental health system. However a tentative comparison of annual mental hospital spending shows considerable variation from less than one US cent per person in Pakistan, up to US$ 22 per person in Bahrain. A group 1 country (Qatar) has the highest per capita expenditure on mental hospitals among reporting countries, and a group 3 country (Pakistan) has the lowest expenditure. Figure 15. Comparison of the percentage of reporting countries in the Eastern Mediterranean Region and globally that have partially or fully implemented involvement of persons with mental disorders and family members in the formulation and implementation of mental health policies, laws and services at national level in the past 2 years Figure 16. Main overall source of funds for care and treatment of severe mental disorders 58 57 27 50 67 50 27 23 23 43 80 70 60 50 40 40 20 10 0 Pe rc en ta ge o f c ou nt ri es Information Policy Early involvement Participation Resources Eastern Mediterranean Region Global N um be r of c ou nt ri es 14 12 10 8 6 4 2 0 Go ve rn me nt Ho us eh old s No ng ov er nm en tal or ga niz ati on s No t r ep or ted Sources of funding for care and treatment of severe mental disorders 12 2 1 7 17 Government mental health spending Comparison of government mental health spending in the Eastern Mediterranean Region with the rest of the world The government (e.g. national health insurance or reimbursement schemes) is ranked as the main overall source of funds for care and treatment of severe mental disorders in 79% of world countries, compared with 80% of the reporting countries of the Region. The Eastern Mediterranean percentage is similar to those of the Americas Region and the Western Pacific Region, lower than those of the European Region and South-East Asian Region, but higher than that in the African Region (see Figure 18). Figure 17. Number of countries reporting annual government spending on component mental health care settings 6 7 4 3 1 2 1 5 2 1 3 1 3 5 8 6 4 2 0 Components of mental health services Inp ati en t a nd da y c are se rv ice s Me nt al ho sp ita l Ps yc hia tri c w ar d i n g en er al ho sp ita l Co mm un ity re sid en tia l fa cil itie s Da y t re atm en t f ac ilit ies O th er re sid en tia l O ut pa tie nt an d p rim ar y h ea lth ca re Me nt al he alt h o ut pa tie nt fa cil itie s Pr im ar y h ea lth ca re fa cil itie s Co mm un ity ca re o r r eh ab ilit ati on O th er o ut pa tie nt fa cil itie s So cia l c are se rv ice s O th er pr og ra mm e c os ts To tal N um be r of c ou nt ri es Figure 18. Percentage of reporting countries in which government funding is ranked the number one overall source of funds for care and treatment of severe mental disorders by WHO region 67 78 86 79 100 77 36 AFR AMR EMR EUR SEAR WPR WHO region 100 90 80 70 60 50 40 30 20 10 0Pe rc en ta ge o f c ou nt ri es in w hi ch g ov er nm en t fu nd in g is t he m ai n so ur ce o f f un di ng fo r ca re an d tr ea tm en t of s ev er e m en ta l d is or de rs 18 Mental health atlas 2014 23% of all countries of the Region provided government mental health spending per capita in the past year compared with 31% of countries globally (see Figure 19). For inpatient services, mental hospitals and outpatient services, the percentage of countries in the Eastern Mediterranean Region providing data was within 2 percentage points of the percentage of countries providing comparable data globally. As noted above the government funding data available for the countries of the Region is based on a small number of countries, and therefore comparisons with other WHO regions has to be extremely cautious. The following four figures use the available data to provide a very rough indication of how the government funding of mental health services in the Eastern Mediterranean Region compares with the rest of the world. The median government funding of mental health inpatient and day care services in reporting countries of the Region is US$ Figure 19. Percentage of countries in each WHO region and globally that provided per capita government mental health expenditure 27 4 34 42 9 22 25 32 32 22 4 31 36 9 26 4 40 51 27 37 28 49 45 34 23 23 23 31 60 50 40 30 20 10 0 Pe rc en ta ge o f c ou nt ri es Components of mental health services AFR AMR EMR EUR SEAR WPR Global Inpatient Mental hospital Outpatient Total Figure 20. Median government funding of mental health inpatient and day care services in US$, by WHO region Figure 21. Median government funding of mental hospitals in US$, by WHO region 0.09 1.64 49.42 0.45 0.96 35.54 AFR AMR EMR EUR SEAR WPR WHO region 60.00 50.00 40.00 30.00 20.00 10.00 0.00M ed ia n go ve rn m en t fu nd in g of m en ta l h ea lth in pa tie nt a nd d ay c ar e se rv ic es ( in U S$ ) 3.61 1.35 19.65 5.78 0.48 18.49 WHO region 25.00 20.00 15.00 10.00 5.00 0.00 M ed ia n go ve rn m en t fu nd in g of m en ta l ho pi ta ls ( in U S$ ) AFR AMR EMR EUR SEAR WPR 19 0.45, which is very low in comparison with the global median of US$ 29.93. The Eastern Mediterranean Region ranks fifth of the six WHO regions for government spending on mental health inpatient and daycare services (see Figure 20). The median government funding of mental hospitals in countries of the Region is US$ 5.78, which is half of the global median of US$ 11.02. The Eastern Mediterranean Region ranks third of the six WHO regions for government spending on mental hospitals (see Figure 21). The median government funding of mental health outpatient services in reporting countries of the Region is US$ 0.09, which is very low in comparison with the global median of US$ 24.28. The Eastern Mediterranean Region ranks fourth of the six WHO regions for government spending on mental health outpatient services (see Figure 22). The median total government funding for mental health services in reporting countries of the Region is US$ 0.70, which is very low in comparison with the global median of US$ 72.57. There is an apparently discrepancy that the reported figures for spending on mental hospitals exceed the amount reported for total mental health funding; this discrepancy has arisen because of poor response rates to the financing items in the Atlas questionnaire, and the group of countries that reported total government funding was different from the group of countries that reported on mental hospital spending. This emphasizes the caution required interpreting these financial data. The Eastern Mediterranean Region ranked fifth of the six WHO regions for total government spending on mental health services (see Figure 23). 5. Mental health workforce Countries were asked to estimate the total numbers of mental health professionals working in each country by profession. Across the Eastern Mediterranean Region, nurses (including both psychiatric nurses and general nurses working in mental health facilities) make up the largest professional group among the mental health workforce, followed by psychiatrists, psychologists and social workers (see Figure 24). There is approximately one psychiatrist for every four nurses, one psychologist for every six nurses and one social worker for every 16 nurses. 0.00 6.47 0.09 24.80 0.09 72.11 WHO region 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 M ed ia n go ve rn m en t fu nd in g of m en ta l he al th o ut pa tie nt s er vi ce s (in U S$ ) AFR AMR EMR EUR SEAR WPR 0.12 33.42 0.70 96.89 1.17 116.66 WHO region 140.00 120.00 100.00 80.00 60.00 40.00 20.00 0.00 M ed ia n go ve rn m en t fu nd in g of m en ta l he al th o ut pa tie nt s er vi ce s (in U S$ ) AFR AMR EMR EUR SEAR WPR Figure 22. Median government funding of mental health outpatient services in US$, by WHO region Figure 23. Median total government funding for mental health services in US$, by WHO region Mental health workforce 20 Mental health atlas 2014 Other health and mental health workers, other medical doctors and occupational therapists are relatively uncommon. Comparing human resources in 2011 and 2014 (see Table 6) suggests that there have been increases in some specialist staff groups such as nurses, psychiatrists and psychologists; while occupational therapists, other medical doctors and other health or mental health workers have reduced in number across the Region as a whole. The regional averages of the mental health workforce conceal specific changes in individual countries. For example, there have been substantial increases in the number of nurses working in mental health in Bahrain, Kuwait, Morocco, Oman and Pakistan; while the numbers of nurses per 100 000 population has decreased in Lebanon, Qatar, Saudi Arabia and Syrian Arab Republic (see Figure 25). The nursing workforce is numerically stronger in health system group 1 countries compared with group 2 countries. Increases in the mental health nursing workforce between 2011 and 2014 are apparent in group 1 and group 2 (see Figure 26). Too few group 3 countries provided information to allow meaningful comparison. Figure 24. Median rate of health professionals per 100 000 population 5.18 1.31 0.89 0.32 0.12 0.010.18 Type of mental health professional M ed ia n ra te p er 1 00 0 00 p op ul at io n Nurses Psychiatrists Psychologists Social workers Other health or mental health workers Other medical doctors Occupational therapists 6 5 4 3 2 1 0 Table 6. Median rate of health professionals per 100 000 population Type of professional 2011 2014 Nurses (including both psychiatric nurses and general nurses working in mental health facilities) 3.3 5.18 Psychiatrists 0.86 1.31 Psychologists 0.41 0.89 Social workers 0.47 0.32 Other health or mental health workers working in mental health facilities 4.35 0.18 Other medical doctors not specializing in psychiatry 0.28 0.12 Occupational therapists 0.04 0.01 21 Increased investment in the mental health workforce in group 1 countries between 2011 and 2014 is also reflected in the increase in numbers of psychiatrists (see Figure 27); but this is not seen in group 2 countries. Comparison of mental health workforce in the Eastern Mediterranean Region with the rest of the world The average total mental health workforce in the Eastern Mediterranean Region is 14.6 per 100 000 population. This is less than half the comparable global rate of 33.8 per 100 000 population. The Eastern Mediterranean Region Mental health workforce Figure 25. Number of nurses per 100 000 population by country* in 2011 and 2014 Af gh an ist an Ba hr ain Eg yp t Ira n ( Isl am ic Re pu bli c o f) Ira q Jor da n Ku wa it Le ba no n Mo ro cc o Om an Pa kis tan Qa tar Sa ud i A rab ia Sy ria n A rab R ep ub lic 22.7 3.1 8.8 1.5 4.7 19.2 0.8 4.1 12.7 15.4 8.8 10.5 0.80.1 25 20 15 10 5 0N um be r of n ur se s pe r 10 0 00 0 po pu la tio n 2011 2014 Figure 26. Median rate of nurses working in mental health facilities per 100 000 population in 2011 and 2014 by regional health system group Group 1 10.71 12.71 2.37 3.6 Group 2 2011 2014 M ed ia n ra te o f n ur se s w or ki ng in m en ta l he al th fa ci lit ie s pe r 10 0 00 0 po pu la tio n 14 12 10 8 6 4 2 0 Figure 27. Median rate of psychiatrists per 100 000 population in 2011 and 2014 by regional health system group Group 1 2.18 2.95 0.91 0.68 Group 2 2011 2014 M ed ia n ra te o f p sy ch ia tr is ts p er 1 00 0 00 p op ul at io n 3.5 3 2.5 2 1.5 1 0.5 0 * Only countries with data for both 2011 and 2014 are included 22 Mental health atlas 2014 is ranked fourth among the WHO regions for the size of its mental health workforce per 100 000 population (see Figure 28). There is a large difference in workforce between WHO regions from the lowest of 3.7 and 4.7 per 100 000 in the South-East Asia Region and the African Region respectively to the highest of 77.6 in the European Region. Table 7 shows the average number of the various types of mental health staff per 100 000 population in each WHO region and globally and also indicates the rank of the Eastern Mediterranean Region compared with the other WHO regions. The figure quoted in the table is the mean within each region and is therefore different from the median figure quoted earlier in this section. Table 7 indicates that compared with the rest of the world, the Eastern Mediterranean Region has above the average number of other medical doctors working in mental health. The Eastern Mediterranean Region is just below the global average for other paid workers working in mental health. The number of nurses per 100 000 population in the Region is about half the global average, and slightly lower for psychiatrists. The Region has less than a quarter of the global average number of psychologists, social workers and occupational therapists per 100 000 population. 6. Mental health training in primary care Primary care staff are the cornerstone of mental health care. The Atlas 2014 questionnaire asked countries to report the numbers of primary care staff, by profession, who had been trained in mental health care for at least two days in the past 2 years. These numbers were divided by WHO estimates of the total workforce of doctors, nurses and community health workers in each country (the total workforce, not just the primary care workforce). Twelve countries of the Region were able to provide data on training of doctors, and seven provided data on training for nurses and midwives (see Table 8). Figure 28. Total mental health workforce per 100 000 population by WHO region 4.7 42.3 77.6 14.6 3.7 19 To ta l m en ta l h ea lth w or kf or ce pe r 10 0 00 0 po pu la tio n WHO region 90 80 70 60 50 40 30 20 10 0 AFR AMR EMR EUR SEAR WPR Table 7. Average number of mental health staff per 100 000 population in each WHO region and globally Mental health staff AFR AMR EMR EUR SEAR WPR Global EMR rank Psychiatrists 0.3 3.5 1.7 10.5 0.7 1.6 4.2 3 Other medical doctors 0.2 1.6 4.7 5.1 0.4 1.4 2.4 2 Nurses 2.1 15.8 7.9 31.6 1.5 12.2 14.4 4 Psychologists 0.6 5.6 1.0 11.2 0.3 1.9 4.6 4 Social workers 0.1 9.0 0.7 2.8 0.1 1.2 2.9 4 Occupational therapists 0.3 0.8 0.2 3.2 0.1 0.6 1.1 5 Other paid workers 1.0 14.2 10.5 29.0 1.0 4.0 12.4 3 23 Mental health training in primary care Overall, only a small minority of doctors (2.7%), and nurses and midwives (1.6%) had received training. There was a wide range between countries in the percentage of primary care staff receiving mental health training in the past 2 years. The countries in which the greatest percentage of both doctors and nurses and midwives had received training is in group 3. In Atlas 2014, countries were asked to indicate the numbers and proportions of primary care staff trained in mental health for at least two days in the past 2 years. This question is substantially different from the question asked in Atlas 2011, which asked about the broad proportion of doctors and nurses who had received official in-service training on mental health within the past 5 years; therefore direct comparisons between the two atlases are not possible. Comparison of mental health training in primary care in the Eastern Mediterranean Region with the rest of the world The median percentage of primary care physicians globally who have received training in mental health for at least 2 days in the past 2 years is 2.1%, and the corresponding figure for nurses and midwives is 1.7%. The Eastern Mediterranean Region is therefore slightly above the global median for training of primary care physicians and slightly below the median for training of nurses and midwives. Compared with the other WHO regions, the Eastern Mediterranean Region ranks second for the training of physicians and fourth for the training of nurses and midwives (see Figure 29). Table 8. Percentage of primary care staff trained in mental health at least 2 days in the past 2 years (by type of professional) Primary care staff Number of countries reporting Median (%) Range (%) Doctors 12 2.7 0.3–29.2 Nurses and midwives 7 1.6 0.01–51.0 Figure 29. Percentage of primary care staff trained in mental health for at least 2 days in the past 2 years, by WHO region 0.6 4.0 2.4 2.4 2.7 1.6 2.0 0.6 1.4 2.5 3.4 0.9 AFR AMR EMR EUR SEAR WPRP er ce nt ag e of p ri m ar y ca re s ta ff tr ai ne d in m en ta l he al th fo r at le as t 2 da ys in t he p as t 2 ye ar s WHO region 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Physicians/doctors Nurses and midwives 24 Mental health atlas 2014 7. Service availability Residential facilities for persons with mental health problems are provided in mental hospitals, psychiatric wards in general hospitals and community residential facilities. There is at least one mental hospital in each country of the Eastern Mediterranean Region, with the exception of Djibouti, where all the mental health beds are in psychiatric wards in a general hospital.6 The average size of the mental hospitals varies between 14 beds (Lebanon) and 779 beds (Pakistan) with a median capacity of 220 beds. In 14 countries (82% of reporting countries) the size of the mental hospitals is between 100 and 620 beds. There is at least one psychiatric ward in a general hospital in 14 countries in the Region. These are typically much smaller units than the mental hospitals, with average sizes ranging between three beds (Oman) and 60 beds (Djibouti) with a median capacity of 17 beds. Five countries (23%) reported that they have mental health community residential facilities, and the numbers varied widely between one in Qatar and Tunisia; through seven in Lebanon, up to 93 in Islamic Republic of Iran and 344 in Pakistan. The average size of community residential facilities in countries varies between six and 124 beds with a median of 33 beds. Eight countries (36%) reported that they have mental health day care or treatment facilities. Most of these countries have only one or two such facilities, but day treatment is more extensively developed in Islamic Republic of Iran, Tunisia and Pakistan, where there are 117, 48 and 14 day care facilities respectively. Islamic Republic of Iran also has the largest average capacity of day care facilities of 46 places. The median number of places in a day care facility across the countries of the Region which have them is ten. Eighteen countries (82%) reported on the number of mental health outpatient facilities available in the country. The median number of patients seen in a mental health outpatient facility in the Region is 100 per week. Availability of beds per 100 000 population Throughout the Region there is a median of 6.1 psychiatric beds per 100 000 population. This rate varies between 0.8 and 19.8 per 100 000 with higher rates in group 1 countries (see Figure 30). The median number of all psychiatric beds per 100 000 population decreased from 7.0 in 2011 to 6.1 in 2014. The median number of mental hospital beds per 100 000 population is 4.48 (range 0–19.5); and the median number of psychiatric beds in general hospitals per 100 000 population is 0.49 (0–6.8). The majority of countries in the Region do not have community residential facilities, but among the four that do, the median number of beds per 100 000 population is 1.2 (0.4–6.7). Within the Region, 64.3% of psychiatric beds are located in mental hospitals and 35.7% are located in community settings: general hospitals (18.3%) and community residences 6 Somalia did not report on service availability. Figure 30. Median rate of psychiatric beds per 100 000 population by regional health system group Group 1 11.3 6.4 1.7 Group 2 Group 3 M ed ia n ra te o f p sy ch ia tr ic be ds p er 1 00 0 00 p op ul at io n 12 10 8 6 4 2 0 25 Service availability (17.4%). This distribution is almost unchanged from that found in 2011 (see Figure 31). There remains a wide variation between countries in the extent to which their psychiatric beds are located in community settings, such as general hospital and community residential facilities (see Figure 32). In several countries the percentage of mental health beds that are in general hospitals and community residences fell between 2011 and 2014 (Jordan, Oman, Qatar, Saudi Arabia, Sudan, Syrian Arab Republic and Tunisia). Due to the small number of countries reporting, we cannot usefully compare beds available in community residential facilities in 2011 and 2014 at a regional level. At an individual country level, most have remained at a similar level, but in Pakistan (group 3) there has been a substantial development from zero in 2011 to 1.2 per 100 000 in 2014. Availability of day care or treatment facilities per 100 000 population In 2011, in the countries with day care facilities, there was a median of 0.005 day care facilities per 100 000 population. In 2014, the corresponding figure for the Region is still 0.005 day care facilities per 100 000, which indicates that day treatment remains relatively underdeveloped in the Region. Availability of outpatient facilities per 100 000 population Outpatient facilities comprise hospital outpatient departments, mental health Figure 31. Distribution of mental health beds in the Eastern Mediterranean Region in 2011 and 2014 Figure 32. Percentage of all psychiatric beds that were in general hospital and community residences in 2011 and 2014 – countries shown are those with relevant data for both 2011 and 2014 50 0 0 0 0 47 51 21 25 31 16 4 35 20 13 64 62 66 48 24 3033 8 3 8 10 86 14 14 9 10 0 54 5 0 100 90 80 70 60 50 40 30 20 10 0 Pe rc en ta ge o f a ll ps yc hi at ri c be ds 2011 2014 Af gh an ist an Ba hr ain Eg yp t Ira n ( Isl am ic Re pu bli c o f) Ira q Jor da n Ku wa it Le ba no n Mo ro cc o Om an Pa les tin e Pa kis tan Qa tar Sa ud i A rab ia Su da n Sy ria n A rab re pu bli c Tu nis ia Un ite d A rab Em ira tes 2011 16 18 66 17.4 18.3 64.3 Year of Mental health atlas 2014 Pe rc en ta ge d is tr ib ut io n of m en ta l h ea lth b ed s 100 90 80 70 60 50 40 30 20 10 0 Community residential General hospital Mental hospital 26 Mental health atlas 2014 outpatient clinics, community mental health centres and community-based mental health care facilities. In 2011, there was a median of 0.28 outpatient facilities per 100 000 population in the countries of the Region, which was about half the global rate. In 2014, the corresponding figure for the Region was 0.15 outpatient facilities per 100 000, which is lower than in the previous Atlas survey. The median number of outpatient visits per 100 000 has gone up from 279 per 100 000 in 2011 to 1275 per 100 000 in 2014. At first sight, this seems at odds with the minimal change in the number of facilities. However, some countries in the Region have reported that the capacity of their outpatient services was not fully used in 2011 but use has subsequently risen, thus greatly increasing the number of outpatient visits to a relatively stable number of outpatient facilities. A further possible explanation is that although 18 countries reported on the number of facilities in 2014, only 12 reported on the number of outpatient visits. Missing data on the number of visits may have biased the reported median number of outpatient visits per 100 000. Comparison of service availability in the Eastern Mediterranean Region with the rest of the world Compared with global rates, the Eastern Mediterranean Region has relatively low provision of psychiatric beds. The median number of mental hospital beds per 100 000 in the Region of 4.78 is lower than the global median of 6.5 per 100 000 and ranks third compared with other WHO regions (see Figure 33). The Region has fewer psychiatric beds in general hospitals (0.49 per 100 000 compared with 2.14 globally), and beds in community residential facilities (median of 0 per 100 000 compared with 0.15 globally), and ranks fifth and sixth respectively compared with other WHO regions. There is a median of 0.02 day care places per 100 000 in the Eastern Mediterranean Region, which is lower than the global median of 0.01 per 100 000. However, the rate of 0.02 per 100 000 is equal or higher than other WHO regions except the European Region, which Figure 33. Psychiatric beds per 100 000 population in mental hospitals, general hospitals and community residential facilities, by WHO region 8.7 4.8 10.8 6.3 2.1 0.6 2.1 3.5 2.2 2.4 0.5 0.00.8 0.10.1 1.9 34.5 AFR AMR EMR EUR SEAR WPR WHO region 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Be ds p er 1 00 0 00 p op ul at io n Mental hospital Psychiatric beds in general hospital Community residential care beds 27 Service coverage for severe mental disorders is the WHO region in which day treatment is most extensively developed. The median rate of 990 outpatient visits per 100 000 population in the Region is similar to the global median of 1051 per 100 000, and ranks fourth when compared with other WHO regions (see Figure 34). 8. Service coverage for severe mental disorders Coverage is a measure of the number of persons in need who receive care. The Atlas 2014 collected information about coverage of all mental disorders and three forms of severe mental disorder: non-affective psychosis, bipolar affective disorder and moderate– severe depression. The sum of persons with severe mental disorders who received care in the previous year from inpatient and outpatient facilities has been divided by the whole population to give a reasonable estimate of treated prevalence. From among the 22 Eastern Mediterranean Region countries that completed the Atlas questionnaire, relatively few were able to provide these data (see Table 9). For most settings, fewer than five countries provided data. Regional analysis of such limited data is not presented here. Cautious analysis of settings with data from five or more countries is presented - median values based on these small numbers of countries should be regarded only as a rough indication. Figure 34. Median number of outpatient visits per 100 000 population, by WHO region 14 1165 6688 990 320 2321 M ed ia n nu m be r of o ut pa tie nt vi si ts p er 1 00 0 00 p op ul at io n WHO region 8000 7000 6000 5000 4000 3000 2000 1000 0 AFR AMR EMR EUR SEAR WPR Table 9. Number of countries that provided information about the number of persons with mental disorders who received mental health care in the past year Care setting All mental disorders (common and severe) Non-affective psychosis Bipolar affective disorder Moderate–severe depression Inpatient and day care services Mental hospital 13 5 5 5 Psychiatric ward in a general hospital 9 4 4 4 Mental health community residential facility 5 3 3 3 Mental health day treatment facility 5 2 2 2 Other residential facility 3 1 1 1 Outpatient and primary health care services Mental health outpatient facility 8 4 4 4 Primary care facility / clinic 5 1 1 1 Other outpatient health facility or service (e.g. outreach service) 5 3 3 3 Social care services Community care or rehabilitation facility (e.g. day care centres) 2 2 2 2 28 Mental health atlas 2014 The median treated prevalence of all mental disorders in mental hospital is 54 per 100 000 population, and in psychiatric wards of general hospitals is 29 per 100 000 population (see Table 10). The treated prevalence of all mental disorders in mental health outpatient facilities (1158 per 100 000 population) is almost 14 times greater than in the two hospital settings combined. This indicates that from among every 14 patients seen as outpatients, one is likely to be admitted. Among mental hospital treated patients, the treated prevalence of non-affective psychosis and moderate–severe depression are similar (28 and 26 per 100 000 respectively), and both are about five times more frequent than bipolar affective disorder (5 per 100 000). 9. Inpatient care Length of stay Ten countries provided data on length of stay in mental hospitals. In the majority of countries, lengths of stay are most often less than one year (see Figure 35). There are substantial percentages staying 1 to 5 years in Iraq, Syrian Table 10. Median treated prevalence per 100 000 population for settings with responses from five or more countries of the Eastern Mediterranean Region Care setting Type of mental disorder Number of countries Median Minimum Maximum Mental hospitals All mental disorders Non-affective psychosis Bipolar affective disorder Moderate–severe depression 13 5 5 5 54 28 5 26 5 3 0.2 0.2 1151 555 338 259 Psychiatric wards in general hospitals All mental disorders 9 29 0 1017 Mental health day treatment facilities All mental disorders 5 6 0 9.5 Mental health outpatient facilities All mental disorders 8 1158 37 3937 Figure 35. Percentage breakdown of length of stay for inpatients staying in mental hospitals on 31 December of the most recent year for which countries had data to report (most were 2013) < 1 year 1–5 years >5 years Pe rc en ta ge b re ak do w n of le ng th o f s ta y 56 44 45 30 25 40 10 51 13 87 34 38 28 10 10 80 8 55 37 7 7 86 2 3 95 100 100 90 80 70 60 50 40 30 20 10 0 Countries that reported on length of stay Jor da n Un ite d A rab Em ira tes Ira q Le ba no n Pa les tin e Qa tar Sy ria n A rab R ep ub lic Pa kis tan Ira n ( Isl am ic Re pu bli c o f) Ku wa it 29 Continuity of care after discharge Arab Republic, United Arab Emirates and Lebanon; and longer stays of more than 5 years occur most frequently in Jordan, United Arab Emirates, Iraq and Lebanon. Eight countries provided length of stay data for both Atlas 2011 and Atlas 2014. The changes in percentage of patients with lengths of stay greater than 5 years are shown in Figure 36. In Lebanon, Palestine and Kuwait the percentage of patients with length of stay greater than 5 years fell between 2011 and 2014. In Islamic Republic of Iran and Pakistan it has remained low and constant. In Qatar and Jordan the percentage of patients staying more than 5 years has increased. Figure 37 shows a similar graph for length of stay more than 1 year. The percentage of patients staying more than 1 year has fallen in Figure 36. Percentage of patients with length of stay more than 5 years reported in the Atlas 2011 and Atlas 2014 surveys Pe rc en ta ge o f p at ie nt s w ith le ng th o f s ta y m or e th an fi ve y ea rs 70 60 50 40 30 20 10 0 2011 2014 Year of Mental health atlas Iran (Islamic Republic of) Jordan Kuwait Lebanon Palestine Pakistan Qatar Syrian Arab Republic Figure 37. Percentage of patients with length of stay more than 1 year reported in the Atlas 2011 and Atlas 2014 surveys Pe rc en ta ge o f p at ie nt s w ith le ng th o f s ta y m or e th an fi ve y ea rs 90 80 70 60 50 40 30 20 10 0 2011 2014 Year of Mental health atlas Iran (Islamic Republic of) Jordan Kuwait Lebanon Palestine Pakistan Qatar Syrian Arab Republic 30 Mental health atlas 2014 Lebanon, Palestine and Kuwait. It is low and slightly reduced in Islamic Republic of Iran and Pakistan. In Jordan, Qatar and Syrian Arab Republic the percentage of patients with length of stay more than 1 year increased between 2011 and 2014. Involuntary admissions Ten countries provided data on involuntary admissions to mental hospitals. A median of 26% of admissions across the region are involuntary, with a range from 1% to 95% (see Figure 38). The number of countries providing data on general hospitals and community residential facilities is very small. Four countries provided data on involuntary admissions to general hospitals (Djibouti 71%; Lebanon 60%; Pakistan 2%; United Arab Emirates 4%). One country, Pakistan, provided data on involuntary admissions to community residential facilities (34%). Globally, 11.6% of all admissions were involuntary, suggesting that the percentage of admissions that are involuntary in the Eastern Mediterranean Region is higher than the global average. Figure 38. Percentage of total admissions to mental hospitals that are involuntary Pe rc en ta ge o f t ot al a dm is si on s to m en ta l ho sp ita ls t ha t ar e in vo lu nt ar y 44 1 17 25 26 33 36 38 49 95 7 100 90 80 70 60 50 40 30 20 10 0 Countries that reported on involuntary admissions Mo ro cc o Om an Un ite d A rab Em ira tes Ira q Tu nis ia Le ba no n Af gh an ist an Pa kis tan Eg yp t Jor da n Table 11. Percentage of discharged patients who were followed up within 1 month Country Percentage of patients discharged from hospital who had a follow-up visit within 1 month Mental hospital General hospital Afghanistan 1 59 Djibouti Not applicable 92 Jordan 55 74 Palestine 100 Not applicable Pakistan 54 42 United Arab Emirates 85 100 31 Suicide prevention 10. Continuity of care after discharge Six countries provided data about the number of persons who had a follow-up visit within 1 month of discharge from mental hospital and from psychiatric wards in general hospitals (see Table 11). 11. Social support Countries were asked to report on the number of persons who had received social support, such as disability payments, income support or forms of non-monetary support, such as housing support, access to employment and educational assistance. Only five countries of the Region provided data on the number of persons with mental disorders who received social support in the past year (see Table 12). 12. Mental health promotion and prevention The third objective of the Comprehensive Mental Health Action Plan concerns the implementation of strategies for promotion and prevention in mental health. National mental health promotion and prevention programmes exist in 10 (45%) countries in the Eastern Mediterranean Region (see Figure 39). Table 12. Persons with mental disorders who received social support in the past year Country Number of persons with mental disorders who received social support in the past year per 100 000 population Monetary support Non-monetary support Bahrain 300 Unknown Djibouti 17 Unknown Iraq 4 Unknown Pakistan 0.1 36 United Arab Emirates 1.3 0.02 Figure 39. Number of mental health promotion and prevention programmes reported by countries 8 7 6 5 4 3 2 1 0 Af gh an ist an Dj ibo uti Jor da n Ku wa it Le ba no n So ma lia Su da n Sy ria n A rab R ep ub lic Tu nis ia Un ite d A rab Em ira tes Ye me n Ba hr ain Qa tar Lib ya Mo ro cc o Pa les tin e Ira q Om an Eg yp t Isl am ic Re pu bli c o f Ir an Sa ud i A rab ia Pa kis tan N um be r of m en ta l h ea lth p ro m ot io n an d pr ev en tio n pr og ra m m es r ep or te d 32 Mental health atlas 2014 Comparison of mental health promotion and prevention in the Eastern Mediterranean Region with the rest of the world Globally, 41% of countries have mental health promotion and prevention programmes, which is the same percentage as in the Eastern Mediterranean Region. The Region is correspondingly positioned in mid-range for percentage of countries with more than one prevention and promotion programme when compared with the other WHO regions (see Figure 40). 13. Suicide prevention Globally, suicide was the cause of 804 000 deaths in 2012.7 Suicide prevention is a priority, and Target 3.2 of the Comprehensive Mental Health Action Plan aims for a 10% reduction in suicides by 2020. The Atlas 2014 asked countries to report on suicide rates and on their suicide prevention strategies. Three countries in the Eastern Mediterranean Region reported that they have developed national suicide prevention strategies: Islamic Republic of Iran, Palestine and Tunisia. In many countries throughout the world, vital registration systems are poorly developed and consequently there are issues of underreporting of suicide. Five countries reported the number of suicide deaths (see Table 13). All of these rates are lower than the global, age-standardized suicide rate of 11.4 per 100 000 population. 14. Core mental health indicator set Specific reports on mental health activities have been produced in half of the countries in the Eastern Mediterranean Region in the past 5 years (see Table 14). Most other countries in the Region have reported mental health activities in general health statistics. Two countries have not compiled a mental health report in the past 2 years, and one country did not submit a response to this item. Comparison of reporting of core mental health indicator set in the Eastern Mediterranean Region with the rest of the world The Eastern Mediterranean Region compares favourably with other regions for reporting of mental health data (see Figure 41). The Region ranks second for specific mental health reports for public and private sectors, and for public sector only. A smaller percentage of countries of the Region have not compiled mental health data in the past 2 years than in all but one other WHO region. Figure 40. Percentage of countries in each WHO region with more than one mental health prevention and promotion programme 32 31 51 41 45 52 Pe rc en ta ge w ith m or e th an o ne m en ta l he al th o r pr om ot io n pr og ra m m e WHO region 60 50 40 30 20 10 0 AFR AMR EMR EUR SEAR WPR Table 13. Crude suicide rates Country Crude suicide rate per 100 000 per year Bahrain 1.6 Iran (Islamic Republic of) 2.5 Palestine 0.7 Pakistan 4.4 Tunisia 0.4 7 Preventing suicide: a global imperative. 33 Discussion Discussion All 22 countries in the Eastern Mediterranean Region submitted data for the Mental health atlas 2014. Items such as policy, legislation and stakeholder involvement were answered comprehensively by all countries. However, other items, particularly those pertaining to finances, service use and suicide, were answered by only a minority of countries. This has severely constrained the scope of analysis of the Regional review, but also illustrates of significant issues relating to budgetary and service planning and information systems, which will be discussed further. The Atlas survey has highlighted the scope for development of leadership and governance in mental health, and this is indicated by the total absence of fully implemented mental health policies and near total absence of fully implemented mental health legislation. Compared with other WHO regions, the Eastern Mediterranean Region has been the most active in recently publishing and reviewing mental health policies and plans. However, where present, mental health Table 14. Availability of mental health activity reporting in the past 2 years Availability/status of mental health reporting Number of countries % No mental health data have been compiled in a report for policy, planning or management purposes in the past 2 years 2 10% Mental health data have been compiled for general health statistics in the past 2 years, but not in a specific mental health report 8 38% A specific report focusing on mental health activities in the public sector only has been published by the health department or any other responsible government unit in the past 2 years 8 38% A specific report focusing on mental health activities in the public and private sectors has been published by the health department or any other responsible government unit in the past 2 years 3 14% Figure 41. Reporting of mental health data in the past 2 years, by WHO region 21 39 10 5 40 19 13 38 36 40 38 46 30 42 30 21 28 38 31 20 42 14 3 12 14 18 10 4 Pe rc en ta ge o f c ou nt ri es in ea ch W H O r eg io n Reporting of mental health data AFR AMR EMR EUR SEAR WPR Global No mental health data compiled in past two years Mental health data compiled only for general health statistics Mental health specific data compiled in past two years for public sectors Mental health specific data compiled in past two years for public and private sectors 34 Mental health atlas 2014 policies are only partially implemented and many require revision to bring them in line with internationally agreed human rights instruments. The lack of effective policies and governance providing a framework for development has also affected stakeholder involvement, which is very underdeveloped in the Region. The strengthening of leadership and governance in the Region with involvement of stakeholders would be important steps in influencing and catalysing the development of mental health resources in order to address the increasing burden of mental illness. The Atlas 2014 survey also shows that the majority of countries could not provide specific data on mental health spending, and this suggests a lack of a specific budget for mental health. In the absence of a current specific mental health budget it is difficult to formulate a clear framework for mental health resources development. Clarification of budgets and budgetary planning linked with development is a clear opportunity for a focused strengthening of mental health leadership and governance. The overall trend in the Region of increasing specialist mental health staff, such as nurses, psychiatrists and psychologists, is encouraging. However, the mental health workforce has decreased in some countries. The fall in psychiatrists per 100 000 in group 2 countries, compared with an increase in group 1 countries, suggests that sociopolitical and economic factors may be a factor influencing the availability and mobility of mental health resources within the Region. Key factors to consider in mental health workforce planning are the retention and attraction of skilled mental health professionals. Alongside consideration of the specialist mental health workforce, the general health workforce is accessible to far greater numbers of people with common mental health problems. The ability of primary care to respond and provide cost-effective interventions for mental health problems can be strengthened by mental health training for primary care staff. The Atlas 2014 findings indicate that only a small minority of primary care staff (2.7% of physicians and 1.6% of nurses and midwives) have received at least 2 days of training in mental health in the past 2 years. These figures are similar to the global medians. This is therefore an area of potential development to address the goals of the Comprehensive Mental Health Action Plan. There is a large variation of mental health facilities in countries across the Region, which is at least in part associated with the availability of resources and political stability (for example: progressively fewer psychiatric beds per 100 000 population comparing group 1 to group 2 and group 3 countries, and fewer nurses and psychiatrists per 100 000 population in group 2 than group 1 countries). Nevertheless there are examples of countries with relatively meagre resources or that are dealing with crises or political unrest where meaningful progress towards the goals of the Comprehensive Mental Health Action Plan have already been made, for example: increased availability of psychiatric beds in community residential facilities in Pakistan; mental health promotion and prevention programmes in Djibouti and Pakistan; and reduced length of inpatient stays in Palestine. Compared with other WHO regions, the Eastern Mediterranean Region has relatively low levels of psychiatric beds, particularly in general hospitals and community residential facilities, and the distribution of psychiatric beds between mental hospitals, general hospitals and community residential facilities in the Region has not changed between 2011 and 2014, which at first sight suggests that there may be inertia in the provision of inpatient services. However, the median total number of psychiatric beds per 100 000 35 Discussion population fell between 2011 and 2014, and there has also been a reduction in the median number of outpatient facilities per 100 000 population. These trends may represent the lack of sustainable policies for maintaining mental health infrastructure or possibly even disinvesting in mental health infrastructure. Unfortunately financial data are not available to confirm or refute this hypothesis. However, another possible explanation for this trend is that there is more focused use of current resources and thus restructuring of current infrastructure to create fewer but more efficient units to provide for mental health care. This has some support in that there has been a more than four-fold increase in the median number of outpatient visits in 2014 as compared to 2011. The increase in outpatient visits may also be partially explained if care has shifted from to the community following the reduction in psychiatric inpatient beds. This may represent changes in cultural attitudes and possibly destigmatization of mental disorders, which will have a long-term impact on healthcare consumption behaviour. Careful consideration may need to be taken to ensure that current policies that influence development of mental health infrastructure will be in line with meeting the demand for mental health consumption. Further research may also be beneficial into the cultural changes that have increased the consumption of mental health outpatient services to better help inform changes to existing policies and help with longer-term mental health resource development planning. There is a large range in the numbers of national mental health promotion and prevention programmes, and unlike the treatment services, this appears to be irrespective of a country’s development or wealth as represented by the health system grouping. This suggests that there is capacity for promotion and prevention programmes in all countries. Yet more than half of countries in the Region have not yet started to address mental health promotion and prevention programmes, and for those countries this represents an important opportunity. Although almost all countries reported that they have captured and reported on mental health data over the past 2 years, this regional analysis indicates that there are significant and widespread gaps in the data collection and highlights that current information systems may not be in-line with target indicators of the Comprehensive Mental Health Action Plan and Mental health atlas. The failure of many countries to report on service coverage, length of hospital stay, follow-up of patients after discharge from inpatient care and provision of social support in the community not only highlights the need for improved information systems, but also suggests a lack of leadership and governance structures with service user and carer participation for the transition of care to community settings. Suicide is poorly reported across the Region, and the majority of countries do not have any suicide prevention strategies in place. This presents an important opportunity for the development of prevention strategies respecting the social, religious and cultural aspects of suicide and suicide reporting in the countries of the Region. Baseline comparison with the targets of the Comprehensive Mental Health Action Plan 2015–20 The Mental health atlas 2014 was revised from previous versions of the Atlas to focus on the targets and indicators identified in the Comprehensive Mental Health Action Plan. In the final section of this review, the extent to which the Eastern Mediterranean Region measures up in 2014 against the six global targets for 2020 is examined. 36 Mental health atlas 2014 Global Target 1.1. 80% of countries will have developed or updated their policy/plan for mental health in line with international and regional human rights instruments (by 2020). Although 55% of countries of the Region have updated their mental health policies in the past 5 years, many are not compliant with some or all international human rights instruments. In 2014, seven countries of the Region, or 32%, are compliant with all five of the five measured components of human rights and therefore meet the Action Plan target; although no country of the Region claims that these policies are as yet fully implemented. If this target is to be achieved in the Region, policies need to be updated in line with human rights instruments in at least 11 more countries by 2020; and strong leadership is required to ensure that these policies are properly resourced and implemented. Global Target 1.2. 50% of countries will have developed or updated their law for mental health in line with international and regional human rights instruments (by 2020). 73% of countries of the Region have mental health legislation (either stand-alone or integrated into other legislation), but as with policy this is often not compliant with some or all international human rights instruments. In 2014, six countries of the Region, or 27%, are compliant with all five measured components of human rights instruments and therefore meet the Action Plan target; although none of these country states that these laws are fully implemented (five of the six state the legislation is available but not implemented, one states it is available and partially implemented). If this target is to be achieved in the Region, mental health legislation in line with human rights instruments needs to be updated and enacted in five more countries of the Region, along with appropriate governance to ensure that mental health laws are implemented in all countries. Global Target 2. Service coverage for severe mental disorders will have increased by 20% (by 2020). In order to monitor and assess this indicator a current baseline of service coverage needs to be established. Our current information does not properly establish this baseline. First, the denominator for calculating coverage is the total population at risk, rather than the total population in need. Secondly, the reporting of numbers of people with severe mental disorders treated is available only for 13 countries at the level of the mental hospital and nine at general hospital and eight at mental health outpatient levels. If the treated prevalence in mental health outpatient facilities, currently at the level of 1158 per 100 000 population (based on eight countries) is to increase by 20% by 2020, then the target is 1390 per 100 000 population. Global Target 3.1. 80% of countries will have at least two functioning national, multisectoral mental health promotion and prevention programmes (by 2020). According to responses to Atlas 2014, nine or 41% of countries of the Region have two or more functioning programmes. Among the other 13 countries, only two have one programme, the remaining 11 have no functioning national promotion or prevention programmes. To meet the target by 2020, the nine countries with two or more programmes must continue to have eligible programmes, and a further nine countries of the Region must establish two or more national promotion or prevention programmes. Global Target 3.2. The rate of suicide in countries will be reduced by 10% (by 2020). This target requires a current baseline against which to measure progress in 2020. Only five countries (23%) reported rates of suicide in the Mental health atlas 2014 survey, with a median of 1.6 suicides per 100 000 per year. A reduction by 10% suggests a target of less 37 Discussion than 1.44 suicides per 100 000 per year. However the currently reported rates may underestimate the true suicide rate due to possible underreporting for social, religious and cultural reasons. There is an urgent need to work towards establishing accurate suicide reporting in countries of the Region. Global Target 4. 80% of countries will be routinely collecting and reporting at least a core set of mental health indicators every 2 years through their national health and social information systems (by 2020). Although 19 countries of the Region have produced reports on mental health data (either dedicated reports or reports on mental health in general health statistics), it is clear from the responses to the Atlas questionnaire that the extent of mental health information is limited in most countries of the Region. Only one country reported on all the indicators, and for several sections that country reported from a region rather than the whole country. With the regional framework for implementation of the Comprehensive Mental Health Action Plan, the Regional Office for the Eastern Mediterranean has provided a core set of indicators that countries can incorporate into their health management and other information systems or collect by periodic surveys in order to monitor progress towards the targets of the Action Plan. The current status of the Region in relation to the 2020 targets of the Comprehensive Mental Health Action Plan is summarized in Table 15. With each biennial Atlas survey the percentage progress towards achieving the 2020 target should increase towards 100% by 2020. In order to progress from the current situation to achieve the global targets and goals of the Comprehensive Mental Health Action Plan, the Region needs to commit to early and sustained mental health development over Table 15. Extent to which the global targets of the Comprehensive Mental Health Action Plan have been met at baseline in 2014 Targets set out in the Comprehensive Mental Health Action Plan (2013–2020) to be achieved by 2020 Status of Eastern Mediterranean Region in Atlas 2014 Percentage progress towards achieving the 2020 target Policy: 80% of countries will have developed or updated their policy/plan for mental health in line with international and regional human rights instruments. Seven or 32% of countries have contemporary mental health policies compliant with international human rights instruments 40% Legislation: 50% of countries will have developed or updated their law for mental health in line with international and regional human rights instruments. Six or 27% of countries contemporary mental health legislation compliant with international human rights instruments 54% Coverage: service coverage for severe mental disorders will have increased by 20%. Treated prevalence in mental health outpatient facilities, of 1158 per 100 000 population Atlas 2014 establishes baseline 3.1. Prevention and promotion: 80% of countries will have at least two functioning national, multisectoral mental health promotion and prevention programmes. Nine or 41% of countries have two or more functioning programmes 51% 3.2. Suicide: the rate of suicide In countries will be reduced by 10%. Median of 1.6 suicides per 100 000 per year based on five reporting countries. Atlas 2014 establishes baseline, but this is inadequate due to low response rate and underreporting. Information: 80% of countries will be routinely collecting and reporting at least a core set of mental health indicators every 2 years through their national health and social Information systems. One or 5% of countries reported on all the indicators in Atlas 2014, 6% 38 Mental health atlas 2014 the next 6 years. The Eastern Mediterranean regional framework for scaling up action on mental health8 along with its accompanying briefing documents and resources provides guidance on how this can be achieved. Success will depend on prompt establishment of strong leadership for mental health in each country empowered with sufficient information and effective governance of resources to plan and deliver. Key partnerships need to be forged, none more important than service user and carer participation. The mental health atlas survey, with Region-specific modifications and interim indicators, will be repeated every 2 years to assist in monitoring progress. WHO will also provide technical advice and support to countries as they work towards implementation of the regional framework. Countries who succeed in achieving these targets will be making a major contribution to their populations in achieving the overall goal of the Comprehensive Mental Health Action Plan to “promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability for persons with mental disorders”. 8 WHO Regional Committee for the Eastern Mediterranean resolution EM/RC62/R.5 scaling up mental health care: a framework for action. Cairo: WHO Regional Office for the Eastern Mediterranean; 2015 (http://applications.emro.who.int/docs/ RC62_Resolutions_2015_R5_16582_EN.pdf?ua=1, accessed 4 February 2016).
Mental disorders have a profound effect on individuals, their families and society. The Mental health atlas 2014 provides up-to-date information on the availability of mental health services and resources across the WHO Eastern Mediterranean Region. This is the first time that all the countries of the Region have participated and contributed to this exercise. The results provide an invaluable resource that will assist stakeholders to identify gaps in current provision and inform decisions around increasing resources to scale up services for mental health, and support the monitoring of progress towards global and regional targets.