Nepal Addressing mental health in Addressing mental health in Nepal ISBN 978-92-9021-021-4 © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO 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 WHO 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 WHO be liable for damages arising from its use. Printed in India Nepal Prepared for the Ministerial Roundtable of the 75th Session of the WHO Regional Committee for South-East Asia 6th September 2022 Addressing mental health in Source: World Bank (https://data.worldbank.org/, accessed 25 July 2022). GDP per capita USS UHC coverage index Literacy (15+) Over 65 years Age-dependency ratio Under 14 years 1223 (2021) 53 (2019) 68% (2020) 1.8 million (2021) 51 (2021) 8.3 million (2021) Population 29.7 million (2021) Life-Expectancy in years 71 (2020) Addressing mental health in Nepal2 Treatment gap • The National Mental Health Survey 2020 revealed that about one quarter (23%) of adults had sought some type of treatment for their mental disorder. Thus the approximate overall treatment gap is 77%. Of the 23% that had sought treatment, 8.8% sought treatment from non-specialized doctors, 6.7% from faith healers and 6.5% from psychiatrists. • It was also found that 40% of those affected had talked about their symptoms with someone, mainly spouses and close family members. • The National Mental Health Survey of 2020 found that the current prevalence of mental disorders among adults was 4.3%, while the lifetime prevalence of such disorders among adults was 10%. The current and lifetime prevalence was highest among the 40–49 years age group. • The current and lifetime prevalence of mental disorders among males was 12.4% and 3.4% respectively, while among females it was 8.0% and 5.1%, respectively. • “Suicidality” (current suicidal thoughts, lifetime suicidal behaviour and the likelihood of committing suicide in the future) was 7.3% among adults, with 6.3% of the population being at low risk, 0.3% at moderate risk and 0.6% at high risk. • The National Mental Health Survey also found that the prevalence of mental disorders among adolescents (13–17 years) was 5.2%, with neurotic and stress-related disorders being the highest at 2.8%. The prevalence of current suicidal thoughts in this cohort was 3.9% while 0.7% had attempted suicide at least once. The burden of mental health problems Prevalence among those over 18 years and above Mood disorder Bipolar affective disorder Major depressive disorder Schizophrenia and associated disorder Neurotic and stress related disorders Suicide behaviour disorder Alcohol use disorder Other substance use disorder 0%Current Lifetime 1.4 % 3.0 % 0.1 % 0.2 % 1.0 % 2.9 % 0.1 % 0.2 % 3.0 % 0.9 % 4.2 % 0.2 % 1% 2% 3% 4% 5% Sources: National Mental Health Survey 2020 Factsheet (Adults), Nepal Health Research Council, Nepal (http://nhrc.gov.np/wp- content/uploads/2020/09/Factsheet-Adults-1.pdf, accessed 25 July 2022). World Health Organization 3 Mental health policies, programmes and laws • Mental health care has been included in the list of basic health services in Sub-Section 4(e) of Section 3 of the Public Health Services Act 2075 (Nepali calendar). • Section 6.17.5 of the National Health Policy 2019 features a strategy to expand mental health services integrated into overall health systems. There is no standalone mental health policy in Nepal. • The National Mental Health Strategy and Action Plan 2020 details actions for mental health in the country for the next five years in line with the government’s five-year development plan. The guiding principle is to ensure easy and equal access to high- quality mental health services integrated into primary health care (PHC). • Though there is no specific law for mental health. The Act relating to Rights of Persons with Disabilities 2074 (2017), Sections 35 and 36, mentions service facilities to be provided to people with mental or psychosocial disabilities in line with the UN Convention on the Rights of Persons with Disabilities (UNCRPD). • Nepal has many nongovernmental organizations (NGOs), both international and national, working in the mental health field. Similarly, many of the medical universities are also implementing mental health programmes in district hospitals as part of their teaching programme for medical and psychiatry residents. These resources can be tapped and better coordinated to improve mental health services in the primary health care centres and district hospitals. The National Health Policy has a specific section on mental health. Mental health is included in the list of basic services of the Public Health Care Act. The National Mental Health Strategy and Action Plan 2020 specifies activities for the next five years. There is no specific mental health law, but some aspects are covered in the Act on the Right of Persons with Disabilities 2017. Addressing mental health in Nepal4 Prevention and promotion activities: organization and coverage • There is little multisectoral involvement in mental health care. Since mental health is an emerging priority in Nepal, stakeholders in other sectors have yet to fully integrate mental health services into their programmes. Nevertheless, social protection programmes such as prevention of gender-based violence, child protection or disability management are increasingly integrating mental health components into their projects. Similarly, sectors such as migrant worker health and education are gradually including mental health into programme plans. • On advocacy, there are many active NGOs in Nepal conducting work related to mental health, including one run by people with lived experience of mental health conditions. NGOs are playing a major role in advocacy and demanding rights- based mental health care. NGOs have also been active in providing services for child protection, gender-based violence, people with developmental disorders (such as autism and Down syndrome), inpatient treatment and rehabilitation for alcohol and substance use disorders, or homeless people with mental disorders. • Awareness, promotion and prevention: awareness-raising, mental health promotion and prevention activities for mental disorders are by the government and several NGOs. These activities include regular radio programmes, distribution of leaflets and pamphlets to raise awareness, as well as dissemination of audio-visual information through social media. These efforts do not occur systematically but are typically centered around specific projects or observance of global advocacy events such as International Suicide Prevention Day or World Mental Health Day. • Several organizations run helpline services for mental health in general and suicide prevention specifically, though few of them operate round-the-clock. • Many private schools have counsellors, but public or government schools do not. The Ministry of Health and Population, however, has initiated a school nurse program wherein efforts are underway to integrate a package of school mental health interventions. • The government has started supporting NGOs to work with people with mental disorders who are experiencing homelessness. The government uses a private–public partnership (PPP) model to release applications for funds to NGOs who help in the treatment and rehabilitation of homeless World Health Organization 5 Mental health services: organization and coverage • The Mental Health Strategy and Action Plan 2020 is based on the National Health Policy 2019 and envisages providing mental health care at the PHC level and integrated into general health care as the main objective. These strategic objectives are at early stages of implementation. • Although the government has plans to strengthen the Mental Health Directorate at the Ministry of Health and Population, currently the mental health programme in the country is governed by a unit within the Ministry that is responsible for noncommunicable diseases (NCDs) in addition to mental health. There are no dedicated persons for implementing mental health programmes at provincial- and district-level administrations. • Nepal is implementing the WHO Special Initiative on Mental Health (SIMH) by developing a detailed multiyear workplan. An investment case for mental health in Nepal is being carried out. The findings will be used to advocate to the government for more investment in mental health. Human resources per 100 000 population 0.6 (183 only 33 in govt) Psychiatrists 0.1 (31, only 2 in govt) Psychologists 0.4 (123, only 33 in govt) Mental health nurses 0 Social workers 0 Occupational therapists Source: Mental health atlas, 2020 data Addressing mental health in Nepal6 • The recording and reporting tools relating to mental health have been revised and are integrated into the Integrated Health Management Information Section (IHMIS) of the Department of Health Services. However, implementation of these tools needs ongoing support and review. • Many publications on mental health research are now available in peer- reviewed journals. Nepal has conducted a National Mental Health Survey in 2019 with technical and funding support from WHO. Therefore, Nepal has enough capacity to do interventional research. Health Infrastructure Public hospitals Non-public health facilities Primary health care (PHC) centres Health posts PHC outreach clinic sites Mental hospitals Psychiatric units in general hospitals Mental health beds per 100 000 population Govt per capita expenditure on MH US$ Sources: DoHS. Annual report 2075/76 (2018/2019) (https://dohs.gov.np/wp-content/uploads/2020/11/DoHS-Annual-Report- FY-075-76-.pdf, accessed 25 July 2022); Mental health atlas, 2020 data Mental health information system and research • List of 11 essential psychotropic drugs is included in the free essential drugs list of the government to be made available at the PHC level for doctors and paramedics to prescribe in accordance with the national protocol. • There is limited capacity to forecast procurement needs of medications because of lack of accurate recording and reporting of mental health cases at the PHC centre. • The government has started to appoint school-based nurses, whose main responsibility is to educate students on health matters and attend to minor medical issues in students. 125 2,168 196 3,806 12 532 6 (150 beds) 25 (360 beds) 1.2 0.06 World Health Organization 7 Issues requiring urgent attention What needs to be sustained and supported Analysis • The National Mental Health Survey 2019 has revealed that more than 75% of people affected by mental health conditions do not get treatment. • There is significant lack of human resources for mental health. • Mental disorders and suicides have reportedly increased in the context of COVID-19. • A National Mental Health Strategy and Action Plan 2020 has been formulated based on the Public Health Services Act 2018, the Public Health Services Regulations 2020 and National Health Policy 2019. This Strategy has the provision to initiate mental health treatment and care services at the primary health care level. • The district primary and secondary care plan is under development with multisectoral involvement and implementation will begin this year. • General hospitals across the country are expanding the availability of acute care beds for mental health. • The Pesticides Management Act 2019 must be implemented rigorously to monitor availability of banned hazardous pesticides in Nepal. Addressing mental health in Nepal8 Main challenges What needs more investment • Lack of knowledge and awareness of mental health among the public which leads to perpetuation of stigma and discrimination. The majority of the people in rural settings believe that mental disorders have paranormal origins and consult traditional healers and shamans. • Lack of availability of adequate mental health services, especially in rural areas. • Absence of dedicated human resources to provide mental health care at the secondary care level. • Low priority accorded to mental health in medical education. • Strengthening of mental health services at district-level hospitals with dedicated human resources, including improving technical and managerial capabilities, referral pathways and follow-up systems. • National-level preventive and promotive programmes, including those for addressing stigma, alcohol use, suicide and mental health of migrants and their families. • School mental health interventions to improve socioemotional skills of adolescents. World Health Organization 9 SWOT Strengths Opportunities The government is deploying staff nurses in schools with the opportunity to expand mental health services. There is a high level of support for mental health at the Ministry of Health and Population. Mental health services and drugs are provided free of charge by the government. Training programmes such as for nursing, psychiatry and clinical psychology are available. Guidelines for community and primary care-level services have been prepared. There is donor interest in addressing alcohol use. The WHO Special Initiative for Mental Health is being implemented with emphasis on developing district mental health services. The National Mental Health Survey was completed in 2020 and country-level data are therefore available. Primary care infrastructure is available, including community workers. Mental health interventions are included in the social health insurance scheme. The investment case on mental health is in the finalization stage. Addressing mental health in Nepal10 Significant treatment gaps remain for mental health conditions. Adequate technical and managerial capacity at the provincial and municipality level to establish and maintain mental health services is necessary. There is a need for significantly strengthening and upscaling primary, secondary and community care systems for mental health. Currently the skilled mental health workforce mainly works in the private sector. A human resources plan or forecasting of human resource requirements for mental health is not available. There is a lack of national- level preventive and promotive programmes, including health programme in schools. Weaknesses Threats Government services are not attractive enough for mental health workers and clinicians. Stigma-related issues have been highlighted in the Mental Health Survey. The increasing number of residential mental health training centres established by private and philanthropic institutions carries the risk of expansion of custodial care contrary to WHO’s recommendations. World Health Organization 11 Notes Addressing mental health in Nepal12
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