Insights on historical milestones of mental health in Nepal: Country profile

Abstract

The present paper has highlighted the mental health development in Nepal. It covers the current state of mental health system and services and a throwback on the significant changes over a period of time. This review grabs a sneak into mental health plan/policies, prevalence; health facilities and human resources, monitoring and supervision, budget allocation, nongovernmental sector involvement, and international agreements. Every description in this paper is substantially based on the progression made at the different time frames, which provides clear understanding of the mental health situation in Nepal. Furthermore, this article throws insights on the main challenges to overcome the current situation on mental health and the associated treatment gap due to stigma toward mental illness, lack of appropriate budget allocation, shortage of human resources, and fear of discrimination.

INTRODUCTION

Nepal is a small landlocked country in South Asia, bordering two large countries: India and China. The country gained independence in 1923 and became a republic and federal state in 2015.[1,2] Nepal's total population is expected to be 2,91,36,808, accounting for 0.37% of the global population in 2020. The majority of the Nepalese people reside in the southern-most plains of the terai region and the central hilly region. Nepal is made up of seven provinces, with the nation's capital located in Kathmandu.[1,2,3]

Nepal ranks 143^rd out of 192 countries, and the Human Development Index (HDI) is 0.602. Nepal stands at 113^th position in the Global Gender Inequality Index,[4] and the largest number of labor force members in the country are in agriculture (69%), followed by services (19%) and industry (12%).[1,2]

In recent years, the number of labor migrants is exceptionally high. Remittances are one of the major sources of income in Nepal, accounting for nearly 25% of all the revenue. Though labor migration has contributed to the national income, it has an enormous adverse impact on mental health due to family separation, deprivation, labor exploitation, forced labor, and trafficking.[5,6] Moreover, nearly a quarter of women over 15 years report being victims of intimate partner violence, which largely influences their mental health.[7]

In 2015, Nepal's health-care sector was transformed, and it adopted a three-tier (federal, provincial, and local) delivery system.[8] At the basic level are community health units, health posts, urban health clinics, and primary health centers. The Ministry of Health and Population (MOHP) formulates overall health plans and regulates, monitors, and evaluates health activities and outcomes.[9,10] The mental health programs in the country are operationalized by the Noncommunicable Disease and Mental Health Section of the Epidemiology and Disease Control Division (EDCD) in the Department of Health Service (DOHS).[10,11]

EVOLUTION OF MENTAL HEALTH SYSTEMS AND SERVICES IN NEPAL

The ancient history of the mental health system was rooted in traditional medicine, which included Ayurveda.[12] Ayurveda had eight disciplines, including Bhootvidya, which dealt with psychological disorders in three ways: “Bheshaj” (medicine), “prayers to God” (psychotherapy), and preventive methods like “Niyam” (behavioral control), “Asan,” and “Pranayam” (yogic exercises).[13,14]

The modern mental health system in Nepal is based on allopathic medicine, which was established in the mid-20^th century along with outpatient mental health services in Bir Hospital (1961), which was later increased to five-bedded inpatient service in 1965 and was further strengthened to 12 beds in 1971.[14]

Eleven years after the first mental health service in Nepal, Tri-Chandra Royal Army Hospital started a 10-bedded neuropsychiatric unit. After the first establishment of rehabilitation center for Nepalese drug abusers in 1976 by Father Thomas Gaffney, several nongovernmental organizations (NGOs) started working in the field of mental health and drug abuse in 1983–1984. In 1984, after the separation of 12-bedded psychiatry department in Bir Hospital, an independent mental hospital was established in 1985, which was then shifted to the current location at Lagankhel, Lalitpur, Patan. In due course of time, mental hospital beds were gradually increased to 25, then to 39, and finally to reach the current capacity of 50 beds. This is the only central government hospital that solely provides tertiary-level mental health care in Nepal.[14]

From 1984, NGOs started to be engaged in mental health programs through community health development projects funded by the United Mission to Nepal (UMN). The first community mental health program was implemented in the Lalitpur district. Slowly, mental health services began to thrive in Nepal's urban hospitals, such as the Western Regional Hospital in Pokhara in 1986 and the Teaching Hospital of Tribhuwan University in Kathmandu in 1996.[14,15]

DOHS was established in 1934.[16] It is responsible for the coordination and delivery of nation-wide mental health-care services. In 2018, the mental health section within EDCD of DOHS emerged as the focal point and is now responsible for planning and organizing mental health activities, coordinating with different stakeholders, and implementing national plans and programs. Furthermore, the curative division of DOHS guides, manages, and controls secondary and tertiary care services, and the management division oversees logistics, supply, and health information system for mental health. Likewise, the National Health Training Center (NHTC) is involved in developing training manuals and organizing and conducting training workshops. All these divisions are closely interrelated and deliver mental health services in an integrated way.[9,10]

Nepal has an enormous gap in the management of mental health problems.[17,18] The World Health Organization (WHO) had launched the Mental Health Gap Action Program (mhGAP) in 2008 to maximize mental health services in developing nations by primary health-care workers through a “task-shifting approach.”[19] Nepal is committed to this program and formulated the Community Mental Health Care Package in 2017,[20] developed the Standard Treatment Protocol (STP) for mental health services in the primary health-care system,[21] and produced mental health training modules for medical officers and health assistants to enhance the capacity of mental health care.[22]As a result, a set of psychotropic medications, including antipsychotics, antidepressants, anxiolytics, mood stabilizers, and antiepileptics, are available at all the levels of health facilities across Nepal. However, due to inconsistency in supply and frequent out-of-stock state, patients are frequently forced to pay out-of-pocket expenses.[9]

Evolution of mental health policies, plans, and strategies

1. National health policies and mental health

   Nepal's first national health policy had failed to incorporate mental health; however, subsection 6.17.5 of the national health policy (2019) had successfully addressed mental health. This policy emphasized access to mental health care and psychological services through primary hospitals by promoting the transfer of knowledge, service-oriented skills, and special training.[23] For the implementation of the mental health agenda as per the National Mental Health Policy, mental services were included in the basic health-care package in 2019.[23]

2. National Mental Health Policy, 1996

   In 1996, for the first time, a National Mental Health Policy was established with a larger vision of providing equity-based minimum mental health care to all needy people in an integrated manner. The policy proposes establishing a separate mental health division in MOHP as well as aims to deliver mental health services to all Nepalis by 2000. Its motive was to protect the fundamental human rights of the mentally ill people, but was ineffective in terms of work plan and action.[24] Moreover, Nepal's ninth 5-year national plan (1997–2002) included a mental health services agenda, but it was never implemented because of low priority on mental health.[25] In spite of greater policy visions like preventing mental illnesses, promoting mental health, destigmatizing prevailing stigma, providing adequate care in all levels of health-care system, and facilitating rehabilitation and cure of mental health issues, Nepalese people are not able to get accessible, affordable, and equitable mental health services, which is attributed to absence of a long-term mental strategy and program formulation in line with the national policy, as well as a low budget allocation.

3. Draft National Mental Health Policy, 2017

   Evaluating and recognizing the contextual changes in mental health care in 2017, MOHP drafted a mental health policy to ensure every Nepalese citizen's rights to mental health care to live a dignified life. It embraced five policies in terms of area and vision to promote mental health, prevent mental illness, enable recovery from mental illness, promote destigmatization and desegregation, and ensure the socioeconomic inclusion of people affected by mental illness through the provision of accessible, affordable, and high-quality health care. This policy guides the allocation of budgets at the federal and provincial levels on the basis of burden of mental illness.[26] Even though the components of this draft policy are relevant, rational, and clear for improving the nation's mental health, it has not been passed by the cabinet ministers till date.

4. The Community Mental Health-Care Package, 2017

   The Primary Health Care Revitalization Division (PHCRD) developed the Community Mental Health-Care Package (CMHCP) with the participation of key stakeholders to fill the existing gap and facilitate successful implementation of the National Mental Health Policy.[20] CMHCP is based on international standards such as mhGAP and Inter-Agency Standing Committee (IASC). To meet the objectives, an STP was formulated for mental health services in the primary health-care system,[21] along with mental health training modules for medical officers and health assistants to improve mental health-care capacity.[20,22]

   Based on this package, PHCRD ensured and scaled up the availability and accessibility of basic mental health and psychosocial support services, as well as training packages. Primary care providers were permitted to prescribe the following psychotropic medications derived from the essential drug list: chlorpromazine, amitriptyline, alprazolam, phenobarbitone, carbamazepine, diazepam, risperidone, fluoxetine, sodium valproate, diazepam, and trihexyphenidyl.[20]

5. The Multisectoral Action Plan for the Prevention and Control of NCDs 2013–2020

   The Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases (NCD MSAP), 2013–2020, integrated and focused on mental health separately. Targets to reduce mental health problems were set. Out of 11 strategic policies to combat NCD problems in Nepal, two are directly related to mental health. They are: 1. reducing commercial and public availability of alcohol and implementing social mobilizing programs to reduce the harmful effects of alcohol and 2. improving the basic minimum care of mental health services in the community and improving competency for case identification and initiating referral at the primary care level.[27]

6. Multisectoral Action Plan for Prevention and Control of Noncommunicable Diseases 2021–2025

   MOHP disclosed the “Multisectoral Action Plan” for Prevention and Control of Noncommunicable Diseases (NCD MSAP), 2021–2025, which was approved by the decision of the council of ministers of the government of Nepal on January 20, 2022, with the goal of reducing the burden of noncommunicable diseases (NCDs) by adopting a health CMHCP policy in all levels. To prevent and control NCDs, four key strategies have been established: 1. political commitment, leadership/governance, lobbying, and partnership; 2. health promotion, risk reduction, and lifestyle modification; 3. strengthening the health system and providing basic health-care services for NCDs; and 4. progressive tracking, monitoring, evaluation, and implementation research.[28] This current action plan is yet to be implemented.

7. The National Mental Health Strategy and Action Plan, 2077 (2020)

   The National Mental Health Strategy and Action Plan, 2020 came into existence in the absence of a National Mental Health Policy in Nepal. The National Mental Health Strategy and Action Plan came up with a vigilant and detailed description of Nepal's plans for mental health care. This strategic action plan consisted of five strategies, which are further described in various plans and activities.

   This strategy was guided by the following four principles: to ensure easy and equal access to high-quality mental health services; to integrate mental health services into primary health care; to cooperate and coordinate with the government, nongovernment, and private sectors; and to provide an evidence-based and comprehensive mental health services.[29] Besides this, Nepal has formulated the Act related to the Rights of Persons with Disabilities, 2074 (2017), which emphasized to ensure additional services for people with mental or psychosocial disabilities. Though Nepal has developed various mental health policies, plans, and strategies, it has yet to pass a reformed national mental health Act [Table 1].[29]

8. Five-year plan, 2019–2024

   Nepal's current 5-year plan embraces mental health care and plans to expand access to basic mental health care at all levels of the health-care delivery system to preserve and maintain the right to mental health for all citizens.[29]

Table 1.

Mental health strategy and plans for activities

Plan No.	Description	Plans and activities
1	Accessible, available, and equitable mental health services	Basic mental health care at the grassroot level Strengthening mental health at secondary and tertiary health-care level Integration of mental health with regular public health programs
2	Resources (people, money, material, skills, and manpower) development and management for quality mental health and psychosocial services	Identification of necessary resources including human resources for essential and quality mental health care Development of the curriculum and different levels of human resources through close coordination and cooperation with universities and health educational institutes Creation of a post in a health institution and announcing for vacancy for regular mental health services in designated health institutions
3	Mental health awareness to reduce existing stigma and discrimination toward mental illness	Development and dissemination of mental health information from various national and local-level media Mental health-related training packages to schoolteachers, school health nurse, and parents throughout the country Establishment of program for increasing awareness on mental health stigma, mental health prevention and promotion
4	Protection of basic human rights of a mentally ill patient	Any discriminatory system and words used in current law for mentally disabled person will be removed and the rights of mentally ill person will be ensured Protection of basic human rights of mentally ill persons as per the international agreement Identification, treatment, and rehabilitation of drug- and alcohol-addicted persons
5	Integration of mental health services-related information into the existing health information system through evidence-based research	Development and initiation of continuous surveillance system for suicidal incidence Promotion of mental health research and modification of existing program on the basis of current evidence from research Determining indicators for suicide and inclusion in current health information system[29,31]

Mental health prevalence trends

There have been various efforts made to gather nation-wide data on mental health illnesses. The first field survey was conducted in Kathmandu in 1984, which revealed a 14% prevalence of mental illness.[30] In 2018, another pilot survey conducted in three districts of Nepal revealed a 13.2% current prevalence of mental disorder.[31] A national representative survey in 2020 from the Nepal Health Research Council (NHRC) revealed the historical prevalence of any mental disorder to be 10%, with a current prevalence of 4.3% [Table 2]. Alcohol use disorder was prevalent at 4.2%, proving it to be the most commonly used psychoactive substance in Nepal. Burden of anxiety disorder was 3%, and lifetime prevalence of major depression disorders was 2.9%, with a current prevalence of 1%. It also revealed that 77% of mentally ill people did not seek treatment or had access to mental health services. The possibility of underestimating the above facts is high due to the existence of various socioeconomic challenges.[18] Suicide is the leading cause of death among women of reproductive age, accounting for 16%, with 21% of suicides occurring below the age of 18 years.[32]

Table 2.

Current situation of mental health in Nepal

Situation	Current status
Mental Health Policy	No
National Mental health Strategy	Yes
National mental health prevalence	4.3%
Prevalence of suicide among women of reproductive age	16%
National mental health treatment gap	77%
Number of health facilities providing mental health services	Five specialist psychiatry hospitals (one public and four private), 19 medical colleges, 364 private hospitals, 27 government hospitals
Number of human resources	144 psychiatrists, three child psychiatrists, 75 psychiatrist nurses, and 30 psychologists
Monitoring and supervision	Yes (15 precoded information formats for mental illness integrated into HMIS)
Budget allocation	0.2% of the national health budget (6.15%)
Professional organization	Yes (PAN)

HMIS=Health Management Information System, PAN=Psychiatrists' Association of Nepal

Health facilities and human resources

In 1961, mental health services began with one mental hospital with two psychiatrist doctors.[14] In 2005, there was one mental hospital, 18 outpatient mental health facilities, and 17 general and teaching hospitals, with inpatient mental units limited to central, zonal, or district level hospitals in Nepal. By the year 2022, it was upgraded to five (one public and four private) specialist psychiatry hospitals. In view of expanding mental health facilities, inpatient and outpatient services were also increased and rendered by 19 medical colleges, 364 private hospitals, and 27 governmental hospitals.[9]

There were only two psychiatrists in the initial phase of mental health service.[14,15] But now, the current human resources have been expanded to 144 psychiatrists as well as three superspecialty child psychiatrists. Out of these, 34 and 110 psychiatrists work in public and private sectors, respectively. There are also 75 psychiatric nurses and 30 psychologists working in private practice. Most of the psychiatric manpower is concentrated in urban areas.[15] Eight hundred and sixty-seven general doctors and primary health care workers, along with 400–500 trained paramedics received brief mental health training by NGOs across the country.[17] In 2005, there were 0.59 human resources working in mental health for every 100,000 people, with only 0.13 being psychiatrists.[24] Until 2005, none of the facilities were specialized for child or adolescent mental health,[24] and by 2015, only 1.5 beds were available for every 100,000 people.[17] There are currently two public rehabilitation centers for alcohol or substance abuse, but several are run by NGOs. There are also three outpatient mental health facilities for children and adolescents [Table 2].[9]

Monitoring and supervision

Monitoring and supervision of mental health services were lacking earlier in primary health center services.[17,33] Mental health information has been integrated into the Health Management Information System (HMIS) in two different formats depending on the type of health facility for appropriate monitoring and supervision. For the basic health centers, there was an information format with 15 precoded diagnoses in which data was recorded, whereas for the primary health care centers and hospitals, information was recorded based on the diagnoses made by medical doctors.[9]

The lack of accurate and realistic mental health information remains the most difficult challenge, owing to drawbacks of health-care knowledge and skills in formulating diagnoses and maintaining an up-to-date information system [Table 2].[33,34]

Mental health budget allocation in Nepal

In the early 21^st century, the total health budget allocated was less than 3% of the national budget. An estimated 1% of the health budget was allocated for mental health.[35] In 2008, the national budget for health was 6.5% and for mental health was 0.8%. Similarly, in 2020, the allocated national health budget was 6.15%, of which only 0.2% was set aside for mental health [Table 2]. This demonstrated a decreasing trend in allocating the national mental health budget.[34] Qualitative evidence show that the proportion of the health budget allocated to mental health is yet to be publicly stated.[36]

Nongovernmental sectors in Nepal

NGOs have been playing an important role in Nepal for policy formulation, protocol development, and the delivery of mental health services.[22,23,29] The UMN previously played an important role in community mental health-care services.[14] In the 1990s and early 2000s, NGOs in Nepal, such as the Center for Victims of Torture (CVICT) and the Transcultural Psychosocial Organization (TPO), provided mental and psychosocial care to victims of civil war and the Bhutanese refugees.[34]

In collaboration with TPO Nepal, the community mental health model developed a Program for Improving Mental Health Care (PRIME) project to make an impact on Nepal's mental health care. The Nepalese Community Mental Health Care Package of 2017 was heavily influenced by PRIME's “Community Mental Health Model.”[37]

Currently, TPO, the Center for Mental Health and Counseling (CMC), and National Mental Health Self-Help Organization (Koshish) are actively providing community-based mental health-care services in Nepal.

International treaties on mental health

Nepal has been continuously participating in and a signatory to the various international movements toward mental health promotion, prevention, care, and protection, for instance, universal health coverage (UHC),[38] sustainable development goals (SDGs),[39] the WHO Mental Health Action Plan,[40] and mhGAP.[19] These initiatives have reflected the growing recognition of unaddressed mental health issues as well as the global burden of mental disorders with significant public health challenges at the national and international levels and attempts to find the best way to address the situation.

Furthermore, to promote mental health in WHO Southeast Asian region, Nepal adopted the Paro Declaration on September 6, 2022, to provide universal access to people-centered mental health-care services in this region.[41] The Paro Declaration envisaged strengthening the capacity of the primary health-care system through an expanded specialized and non-specialized workforce and monitors progress toward UHC,[38] health-related SDGs,[39] and the targets of the WHO Comprehensive Mental Health Action Plan 2013–2030.[40]

Nepal is a signatory to the Universal Declaration of Human Rights, the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and the International Convention on the Rights of Persons with Disabilities (CRPD) to prevent discrimination and foster equal opportunities for people with or without disabilities.[42]

Professional organization

The Psychiatrists' Association of Nepal (PAN) is the only nonprofitable professional organization of Nepalese psychiatrists established in 1990. PAN has been taking a leadership role in the development and implementation of national mental health programs and policies. PAN issues the “Journal of Psychiatrists' Association of Nepal” twice a year. It also organizes national and international workshops and conferences on various themes related to mental health.[25,43]

Hindering factors

Since time immemorial, the cultural context of Nepal has considered the mind and the body as separate entities; hence, mental illness is viewed as being separate from physical illness. Furthermore, mental health issues are viewed as a sign of spiritual dysfunction or a weak mind.[44] Deploring practices in Nepal are still prevalent, such as being chained or locked up, refusing a marriage proposal, and being excluded from community or religious activities.[45] Most people believe that mentally ill people are insane and violent. Hence, people are afraid to open up about what they are going through, and the preferred first modality of treatment is traditional and faith-based healing.[33,34,36] The measurement of the treatment gap was never done before 2017. A study by Luitel et al.[33] in 2017 revealed the shocking evidence that more than 90% of people with mental disorders did not receive treatment for their illness. The National Mental Health Survey, 2020, in Nepal showed a 5% reduction in the treatment gap (75%) in access to mental health care.[18]

Mindset prevailing from ancient time toward mental illness,[45] inaccessibility of mental health care at the grassroot level,[18,24,33] inadequate and unqualified human resources,[33,46] and fear of discrimination[45,46] are the major obstacles mental health promotion and gap in the Nepalese context.

CONCLUSION

Despite the huge burden, mental health care was grossly neglected in the past. However, in recent years, Nepal has made significant stride in developing mental health policies, plans, strategies, and protocols, as well as prioritizing the implementation of mhGAP in primary care settings to reduce mental health problems. Major challenges to overcome the mental health issues are appropriate budget allocation, integration of faith healing and traditional healing systems into the current health system, recruitment of human resources, capacity building of existing human resources, developing a safe environment for people to disclose and get motivated for treatment, and expand partnerships with nongovernmental sectors for equity-based quality access to mental health care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.