ORGANISATION MONDIALE DE LA SANTE I O R L D H E A L T H O R G A N I Z A T I O N
INTERCOUNTRY GROUP MEETING ON THE EM/INT.GRP.MTG.DEV.MHP./13
DEVELOPMENT OF THE MENTAL HEALTH PROGRAMME
Amman, 24 - 28 September 1983
NATIONAL EXPERIENCE
ON THE
DEVELOPMENT OF MENTAL HEALTH CARE
* Dr M. A. Kanaan
* Head, Mental Health Division, Ministry of Health, Amrnan,Jordan
HISMRICAL INFORMATION :- -- - - - - - -. - - - . -
The f i r s t psychiatric hospital i n the area was founded i n 1922
which i s Bethelehen Hospital i n Palestine which w a s originally a
Monastry for the German Camunity ard was granted for that purpose
af ter World War 1 is wer . Other buildings were added un t i l the hospital capacity became
450 beds by 1967 , and at f i r s t doctors who worked i n i t were g.ps.
with interest i n that f i e ld and old methcds of treatment were used
and @*ally No. of s taff increased ard af ter 1967 No. of beds was
reduced t o 320 ard more clinics were opened i n the different c i t i e s
of the West Bank . Bethelehen Hospital ard its Clinic remained the only place t o
serve the people of Palestine ard Jordan unt i l 1963 when the Jordan
Army Medical Services started psychiatric care by a cl inic i n the
Base Military Hospital i n Anman and few psychiatric beds as part of
the chest department ard la ter on a specialbuildirg was established
in side the hospital pards with a capacity of 40 beds ard a resid-
ency prcgramne was started i n 1965 urder the supervision of a qual-
i f ied psychiatrist - the f i r s t psychiatrist i n the East Bank - i n
1975 the psychiatric unit i n the Base Military Hospital i n Amnan was
transferred t o becane a department of psychological medicine i n the
King Hussein Medical Centre , u n t i l a capacity of 40 beds and evers-
ince the No. of staff was increasing with high qualification abroad
for a l l members , as well as more clinics adjoined t o the other M i l -
i ta ry hospitals were opened.
In 1967 af ter the w a r , the Ministry of Health opened two Mental
Hospitdls nearby Aman each with a capacity of 50 beds together with
a central cl inic i n Aman and t o s t a r t with those hospitals were un-
der the supervision of a trained psychiatrist and la ter on a quilified
psychiatrist took place a rd residency progranme w a s initiated and
p l a c e and a r e s i d e n c y programme was i n i t i a t e d and o t h e r
members o f s t a f f were a p p o i n t e d and i n 1972 t h e f i r s t
p s y c h i a t r i c n u r s e s t a r t e d work i n t h e s e two h o s p i t a l s and
up t o d a t e f i l i n g s y s t e m f o l l o w e d u p s i n c e 1 9 7 1
1. Demographic I n f o r m a t i o n .
- e s t i m a t e d t o t a l p o p u l a t i o n on i s t J a n u a r y 1983 ( o r n e a r e s t d a t e ) : 20,5C0,000
- P e r c e n t a g e o f p o p u l a t i o n 0 t o 1 5 y e a r s :
50 % - P e r c e n t a g e of p o p u l a t i o n 65 y e a r s and o v e r :
30 % - P e r c e n t a g e o f p o p u l a t i o n i n towns
66 %
11. N a t i o n a l Men ta l H e a l t h P o l i c y :
No n a t i o n a l m e n t a l h e a l t h p o l i c y i s f o r m u l a t e d f o r
t h e c o u n t r y u n t i l p r e s e n t .
b u t a p l a n f o r t h e deve lopement o f m e n t a l h e a l t h
care h a s been drawn up a c c o r d i n g t o t h e f o l l o w i n g :
O b j e c t i v e s :
- i m p r o v i n g t h e p r e s e n t s i t u a t i o n i n m e n t a l h o s p i t a l s
and c l i n i c s .
- I n c r e a s e t h e No. of h e a l t h w o r k e r s a l l l e v e l s and
a d m i n i s t r a t i v e l e v e l a s w e l l . - I n c r e a s e t h e No. o f beds .
- P r o v i s i o n o f m e n t a l h e a l t h c a r e f a c i l i t i e s i n Governo-
r a t e s
S e p a r a t e T a r g e t s :
- M o d e r n i s a t i o n o f t h e p r e s e n t m e n t a l h o s p i t a l s
- P r o v i s i o n o f more f a c i l i t i e s i n t h e s e m e n t a l h o s p i t a l s .
- E s t a b l i s h i n g a modern p s y c h i a t r i c h o s p i t a l o f 200 b e d s
c a p a c i t y . - Change of t h e p s y c h i a t i i c c l i n i c . ( I n Aman (vkry old , very mdll )
- E s t a b l i s h i n g a c e n t r e fo r t r e a t m e n t of dependence ( Not Done yet ) .
- Change a an oLd r e h a b i l i t a t i o n c e n t r e i n t o a p s y c h i a t -
r i c h o s p i t a l .
- Sending doctors & nurses abroad for higher qualifi-
cation in the field.
- Provision of rehabilitation programmes . - Appointment of psych6logists, social workers, Reha-
bilitation officers.
Orqanisational Mechanisms.
1. Establishment of a mental health department in the
Ministry of Health for planning & supervision pf
mental health facilities and its developement and
transforming of the department in to a directory
for mental health services (as soon as possible)
so as to give it sore mobility and freedom in execu- ting its plans. ( We did not succeed yet ) -
2. Establishing mental health unit in general hospitals
(done partially)
3. Training general nurses , as part of their 3 years
curriculum ( 30 hrstheoritical & 6 weeks practical 1
4. Establishing an assistant nursing school in (Alfhais
Psychiatric Hospital) not done.
5. Transferring Al-Fhais psychiatric hospital in to a
teaching hospital
- under graduate medical students ) Jordan University - = - - nursing = 1
- = - - assistant N. = 1 Ministry of Health
6. Granting a special allowance for working with,mentally
ill (25% of thw whole salary)
111-Mental Health Services:
- Number of Mental Hospitals Three: 1 in the West Bank
2 in the East =
- Total numbers of Mental hospital beds: 320 west bank 200 East Bank
- Number o f p s y c h i a t r i c u n i t s i n g e n e r a l h o s p i t a l s
1 i n King H u s s e i n M e d i c a l C e n t r e .
- T o t a l Number o f b e d s i n p s y c h i a t r i c u n i t s : 40
- A d d i t i o n a l p s y c h i a t r i c b e d s p l a n n e d
a ) i n M e n t a l h o s p i t a l s : 200 b e d s ( w i l l be r e a d y i n 1 9 8 4 )
b ) i n p s y c h i a t r i c u n i t s : 50 = (P. Hamzeh M e d i c a l c e n t e r
Under c o n s t r u c t i o n )
- Number of o t h e r s p e c i a l i z e d m e n t a l h e a l t h f a c i l i t i e s
( o u t p a t i e n t c l i n i c s , d a y c e n t e r s , o t h e r s )
C ) P. c l i n i c s :
MOH: ?-Amman c l i n i c 5 days /week - 3
= 2 - I r b i d = 2 days/week
3 , p r i s o n = 1 day / week
M i l i t a r y 4 l.K.H.M.C. c l i n i c 5 days /w .
- - Amman 2.Marka 2 = / = )
3 .Za rqa - - = = / = ) Z a r q a
4 . I r b i d - - = = / = I r b i d
- d n i v e r s i t y C l i n i c Amman
West B.
5 1. Bethe lehem C l i n i c 4 days/W S p e c i a l i s t s
P s y c h i a t r i s t .
2. Nab lus = 2 = / W T r a i n e d P s y c h i a t r i s t
3. Ramal lah - - = =/ = S p e c i a l i s t P s y c h i a t r i s t
4. ToolKarm - - =/ rained P s y c h i a t r i s t ) 5. Geneen = 2 = / W )
P r i v a t e C l i n i c s : ---------------- Amman 7
Z a r q a 1
I r b i d 2
Day C e n t e r s : None
- Number of p s y c h i a t r i s t s :
MOH: Q u a l i f i e d 1 W. Bank : q u a l i f i e d 4
t r a i n e d 5 3
I n t r a i n i n g 4 3
Military : qualified 4 Private: qualified 7
Trained 2 trained 3
In training - - No. of non - specialised doctor in the mental Health
Services : None
- No. of registered psychiatric nurses
MOH: 1
Military:2
West Bank: 7 - 5 Nuns
- Number of other specialized mental health workers
Psycholoqists Social workers Occupational Therapist
MOH : 3 3 1
Military 4 1 - W. Bank 1 4 1
1V Organisation of Mental Health Services:
Until 16/8/1983 Mental health services was represented as
a department of mental health connected directly with the
director of medical services.
But after that date the department was cancelled and each
hospital was connected seperately to the directory of
Medical services
- National coordination of mental Health care.
- Generally there is some coordination between . Ministry of Health , of social affairs, charity societies
- special problems:
- Drug abuse: In 1980 the National Committee for Prevention . of drug and alcohol abuse was established from members
of the following authorities:
- Ministry of Health - Ministry of Social Affairs - - - = Education
- - - = Interior
- University of Jordan -Epilepsy: is mostly: taken care of by the psychi*tric
services
- Mental Retardation:
Up - 16 yrs of age is taken care of by Ministry of Social Affairs +-Charity Societies for mental
retardation . After 16 yrs of age they are either at home or in
the mental sub normality section in Al-Fhais psy-
chiatric hospital
- Mental Health Legislation;
was up dated in 1971
and a photocopy in Arabic is attached.with translation . - Charging of Mental Health Care
Mental Health care is free of charge concerning:
- outpatient services - in - - - -
- Drug Provision - Rehabilitation Programmes.
Our chronic mental hospital was chosen amongst an
industrial area accordingly there are the following
programmes:
1) Sheltered Rehabilitation programme:
a) Employment of patients in hospital work and
they are paid by the (League of friends of
the mentally ill)
b) Actual employment as hospital maids and are
paid by the Government.
2 ) Half-sheltered programme: where patients are
employed in the near by industries, fully paid
but they come back to hospital after work.
3 ) An industrial training workshop is planned to
be built near by the chronic mental hospital in
which patient are trained on most m a 1 crafts
- Links with primary Health services: - There are no links up till now between mental health services and primary health services, except the
referral of cases from couritry clinics or medical
centres specialists clinics in the governorates
for the main psychiatric clinics, or directly to the
hospital. And no programmes towards their integration Yet
v . Trainirg I n Mental Health Care :-
- There are no postgraduate t r a in i rg programme i n psychiatry
f o r dmtor s . But there is a one monthe trainirg programme
f o r the undergraduate medical students of the Jardan Unive-
r s i t y ard almost the sane period for the nursirg students of
the University Nursirg College an3 m r s i r g students of the
Ministry of Health
Nursirg College.
- There a r e no t r a in i rg courses f o r primary care workers
- There a r e t r a in i rg f a c i l i t i e s f o r the postgraduate psychology
students as well as the urder graduates of the University of
Jordan . - Scholarships fo r doctors & nurses
- MOH Since 1971 only 3 doctors i n t ra ining were sent t o U.K. - for postgraduate psychiatric t ra ining i n Edinburg ard Liver pool
University . W.B. Only two t o the Madselay . U . K .
- Military :- Since 1967
8 Doctors t o UK
2 Nurses t o UK
4 Psycholcgists U.S.A. - S t a t i s t i c s
Registered pat ients since 1967
MOH : 16,003
W.B.: 17,000 Military :-
- Other data a r e attached for 1982
General Health Care Information :
Hospitals : 13
Medical Centres 89
Country c l in ics 283
Maternity & C.H. 68 Centres
Dentist c l i n i c s 44
No. of pat ients :- 13112
New cops :- 558
Admissions: - 216
Persontage of pat ients / i l l n e s s Schizophrenia 53 %
Depression 14 % M. Retardation 3 % Newroses 2 %
Monia 1 % Others 2 %
Distr ibut ion of psychiatric / area / t o Amnan c l i n i c :-
!brnan :- 40.4 % Zarqua :- 13.2 % Jarash :- i3.2 %
Sa l t :- 2.0 %
Irbid : - 1.5 % 5C00 patients/year / t o
I rb id c l in i c
r e s t of the cmntry 7 .1 % Private c l in i c s :- a r e estimated t o see an equal No.to t h a t
t
M i l i t a r ; ? Services:- of the Ministry of Health .
Forensic Psychiatry
- Psychiatric unit in military hospital :
There was a prison in the basement for the observation of
psychiatric criminals and offer writihg a report and wittnessing
before the court and if the criminal was mentally ill, he is
treated while in the hospital prison and later on discharged from
the army.
- Ministry of Health . - 6 beds are pr6vided in A1 Fhais psychiatric hospital for observation of psychiatric criminals and writing a report by two
specialists after witnessing before the court, if the criminal
is considered irresponsible, he is detained in the mental hospital,
forensic unit until he is cured and if there are no beds he is
detained in the general section and after improvement he is
discharged after taking the court's agreement.
- There is one day /week clinic in Amman - prison for prisoners who need psychiatric care or addicted prisoners.
VII. Mental Health Research
- Were you aware of the Report on the Scientific Working Group
Meeting on Mental Health Research, Karachi; 6 - 9 June 1981 (EM/MENT/~~) Yes No
- Can you list any ongoing mental health research activities
in your country under one or more of the following headings. Please
give title of project and responsible person or institution.
Type of research Title & responsible institution or person
Epidemiological surveys None
Development of epidemiological
of indicators of mental illness None
Socio-cultural and socio-economic
factors affecting mental health
Type of ~esearch Title & responsible institution or person
Clinical studies (aetiology,
patho-physiology, bio-chemistry
and psycho-pathology of
mental disorders
None
Mental health services research
Mental Health Act. No. 21/1971
Mental Health
Act. 49 : It is possible to establish one or more hospitals
for psychological illnesses and it is also possible to assign
certaih sections in any hospitals for the same purpose and in
each case a specialist or more and the necessary staff should be
appointed.
Act. 50 :
1. Psychologically ill patients are accepted for treatment
inside the hospital or the section either voluntary or compulsory
if :
a. it was necessary to treat him as in-patient
b. his treatment is necessary for the safety of others
c. if by a court order upon medical opinion in cases of and if
it is necessary to :
1. Submit an application to the hospital director
2. a certificate from the specialist in the same meaning
3. final agreement from the director
2. The director or the treating physician can discharge the
patient when he is cured or improved provided that his family
and the director through the date of discharge but if the admission
upon court order, the court's agreement should be taken.
Act. 51 :
Except the court order in c, the Minister of Health if he was
convinced that the reasons for compulsory admission are not
sufficient, he can-order his discharge or prevent his admission.
Act No. 9 / 1961
Article 233
1. If the court had a proof that the criminal was mentally ill in
way to make him unable to realize what he is doing or that it is
forbidden to do that, the court will condemn him but he is consi-
dered irresponsible.
2. If the court,during trial, realized that the criminal is
mentally ill that his trial is impossible. The Court decides
that he should be put under observation for a suitable period
3. If after observation, the Court had a proof that he is
same, (upon a medical report signed by two medical officers), his
trial is recommended otherwise the court decides to detain him
in the mental hospital.
RAPE - Act. 197
- Anyone who rapes another who cannot resist because of mental
or physical deficit or by deceipt is punished by temporary hard
work.
- Mental deficit
It prevents the victim from resistance because of :
- Psychological illness
- Mental illness
like fainting attacks-or madness or sleep even if there is
a consent, this will not be accepted by the court.
Irresponsibility or dimished responsibility
I. MADNESS
Article 91
1. It is supposed that everybody is mentally saineor that
he was mentally saine when he submitted the crime unless otherwise
prooved.
Article 92
1. No punishment to anyone who does anything or leaves it, if it was prooved that at the time of the deed he was unable fo
conceive the care of his deed or he was unable to know that it is
prohibited to do that deed or leave it because of mental disorder.
2. Everyone who is free from punishment according to No. 1, he
should be detained in a mental hospital until it is prooved
by a medical committee that he is cured and no more a danger
for public security
2) DRUNKNESS AND POISONING BY NARCOTICS
Art 93
No punishment to anyone who is unconscious or unable to
decide during the commitment of any deed because of alcohol or
narcotic if he took any without his consent or knowledge.
Discussion of the Report ........................
Drug availability :-
D r . I. Khan asked i f the Mo.tt. has appointed a phychiatrist
i n the dmg camit tee i n Jordan and the answer was not yet, and
he thought that time came t o enphysise this point and may be a re-
cannerdation of a r Meetirg.
Irdicators of Improvement :-
D r . Sartorius inquire3 a b a t any indicators of improvement
of Mental Health care going on with the increase No. of private
psychiatrists , ard the answer was that the on7 y irdicator we
h v e :- 1. I s the reduction of the No. of patient caning i n the Mott
cl inic almost t o the half..
2. I s the diminished No. of accute cases caning to the O.P.C.
Elderly People : -
D r . Donny i s wired about that point a d the answer was
that s t i l l the exteded family is carring so them plus sane
charity societies.
Newrohis :-
D r . Adrnawi inquired about the very low No. of newrotic cases
and the answer that private doctors . see newrotic cases as nslch
as we see psychotic cases.