Author: Haider Naqvi
Position: Psychiatrist
Institution: Aga Khan University Hospital
E-mail: haider.naqvi@aku.edu
Submitted Date: September 25, 2005
Published Date: September 26, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

In the essay by Gilani et al, the authors have quite vividly described the state of mental health care and legislation in Pakistan. Indeed, the situation is one of low awareness and resources, much like other low-income countries in South East Asia. Even at international level there is deep-seated societal ambivalence towards the mentally ill. The so called "human rights" principles have little material effect on the lives of psychiatric patients and create double standards in the exercise of choice [1].

The promulgation of the new mental health ordinanace has indeed been a red letter day in the history of Pakistani legislation. However, how this document translates into real world action, remains to be seen. In Pakistan, 70% of health care services are provided by the private sector, and this too is mostly curative in nature [2]. According to World Health Report (2004), 100% of health care payment is out of pocket for Pakistanis. Most private health care is unregulated. No hospital in Pakistan has JCIAH accredition. Anecdotal reports on abuse of mentally ill individuals is ubiquitous. It is not uncommon to see mentally ill pateints chained with their beds. There is poor provision of psychotropic medication in the government-run hsoptals. Contrarily, one sees a cocktail of 5 medications prescribed by an inadequately trained mental health professional, in private practice. Out of 342 registered psychiatrists hardly 100 to 150 have adequate training. The Pakistan Medical and Dental Council (PMDC) is the sole body for the proper licensing and credentialing of physicians. The problem lies in the implementation of rules and regulations rather than their existence. One sees a chain of psychiatric hospitals, claiming to deliver psychiatric care, with no qualified psychiatrist on their panel. There is no legal action taken against these people, who blatantly exploit patients with mental illness.

All the major tertiary care centers in Pakistan have allied general medical and anesthesia services, yet the provision of modified ECT is deemed only "preferrable" in the new mental health ordinance. Unmodified use of ECT results in serious and potentially life-threatening complications. Similarly, there are other paradoxes in the actual care and legislative protection of people with mental illness. The Federal Authority for Mental Health(FAMA) has played no active role in addressing these glaring inequities, since its organization in 2001. Contrarily, there is a risk that it might become a power broker for bureaucracy and ministry officials, rather than serving the real stake holders.

Essentially, nothing has changed for people with mental illness, except the nomenclature and terminologies. There is still no mercy for people with mental illness in poor and other marginalized communities.

Governmental low health care spending (less than 1% of GNP)is in the context of bigger geo-political situation. Countries major spending is on defense and military armaments. This is in a politically volatile environment with ongoing border conflicts with neighbors. However, there is a need for strong political will, from the government, which oversea the implementation of rules and regulations and protects the rights of people with mental illness.

For a comprehensive solution an active Public-private partnership is required. This requires unified agenda and commitment from both tiers. Any lasting solution has to address the deep-rooted inequities, ethical misconducts and micro/macroeconomic issues.

References
[1] Harding TW. Human rights law in the field of mental health: a critical review. Acta Psychiatr Scand 2000; 101:24-30.
[2] Khattak FH. Financing of health sector in Health economics and planning in Pakistan. Ad-Rays publishers, Islamabad; 1996:44-61.