Mental health services in the Arab world

Abstract

This paper summarizes the current situation of mental health services in the Arab world. Out of 20 countries for which information is available, six do not have a mental health legislation and two do not have a mental health policy. Three countries (Lebanon, Kuwait and Bahrain) had in 2007 more than 30 psychiatric beds per 100,000 population, while two (Sudan and Somalia) had less than 5 per 100,000. The highest number of psychiatrists is found in Qatar, Bahrain and Kuwait, while seven countries (Iraq, Libya, Morocco, Somalia, Sudan, Syria and Yemen) have less than 0.5 psychiatrists for 100,000 population. The budget allowed for mental health as a percentage from the total health budget, in the few countries where information is available, is far below the range to promote mental health services. Some improvement has occurred in the last decade, but the mental health human resources and the attention devoted to mental health issues are still insufficient.

The Arab world is taken to mean the 22 members of the Arab League, accounting for 280 million people. The region has the largest proportion of young people in the world: 38% of Arabs are under 14. Life expectancy has increased by 15 years over the past three decades, and infant mortality has dropped by two-thirds. Around 12 million people, or 15% of the labor force, are unemployed. The quality of education has recently deteriorated, and there is a severe mismatch between the labor market and the education system. Adult illiteracy rates have declined, but are still very high: 65 million adults are illiterate, almost two-thirds of them women. Some 10 million children still have no schooling at all.

The health expenditure estimated as a percentage of gross domestic product is highest in Palestine (13.5%), followed by Lebanon (8.8%), Jordan and Djibouti (8.5%) and Egypt (6.4%) 1. Health services in all Arab countries are provided by public (government) and private sector facilities and out of pocket (this last category representing 63.4% of the total in Sudan, 58.7% in Egypt, 58% in Yemen, 56.1% in Morocco and 54.9% in Syria). In some countries insurance systems contribute to the provision of the service. Non-governmental organizations (NGOs) have come to be recognized as an important actor in the provision of health services, especially in countries with internal instability (in particular, Lebanon in late 1980s and Palestine now).

The mental health expenditure as a percentage of total health expenditure is not available in most Arab countries and not reported by the officials. Only three Arab countries have provided an estimate: Qatar (1%), Egypt (less than 1%) and Palestine (2.5%).

There are no projections on the burden of mental disorders specific to the Arab world. Only two countries (Lebanon and Iraq) so far conducted national studies using comparable methodology, based on the World Health Organization (WHO) World Mental Health Surveys 2,3. Two other studies were conducted in Morocco 4 and Egypt 5 using different methodologies. The lifetime prevalence of any anxiety disorder among adults was 16.7% in the Lebanese study and 13.8% in the Iraqi survey; that of any mood disorder was, respectively, 12.6% and 7.5%. The study carried out in Morocco reported a point prevalence of 9.3% for generalized anxiety disorder and 26.5% for major depressive disorder, while the Egyptian study reported a point prevalence of 4.8% for anxiety disorders and 6.4% for mood disorders.

Table 1 shows the data concerning the availability of mental health policies in the various Arab countries, obtained through ministries of health, the Eastern Mediterranean Region (EMRO) office of the WHO, national psychiatric societies and national psychiatric leaders. Six out of 20 countries do not have a mental health legislation and two do not have a mental health policy. There is no information for Mauritania and Comoros.

Table 1.

Table 1 Mental health policies in Arab countries

Country	Mental health policy (year)	Substance abuse policy (year)	National mental health programme (year)	Mental health legislation (year)
Algeria	Yes (?)	Yes 1990	Yes 2001	Yes 1998
Bahrain	Yes 1993	Yes 1983	Yes 1989	Yes 1975
Djibouti	No	No	No	An old French legislation
Egypt	Yes 1978	Yes 1986	Yes 1986	Yes 2009
Emirates	Yes (?)	Yes (?)	Yes 1991	Yes 1981
Iraq	Yes 1981	Yes 1965	Yes 1987	Yes 1981
Jordan	Yes 1986	Yes 2000	Yes 1994	Yes 2003
Kuwait	Yes 1957	Yes 1983	Yes 1997	No
Lebanon	No	No	Yes 1987	No
Libya	Yes (?)	No	Yes 1988	Yes 1975
Morocco	Yes 1972	Yes 1972	Yes 1973	Yes 1998
Oman	Yes 1992	Yes 1999	Yes 1990	Yes 1999
Palestine	Yes 2004	Yes 2004	Yes 2004	Yes 2004
Qatar	Yes 1980	Yes 1986	Yes 1990	No
Saudi Arabia	Yes 1989	Yes 2000	Yes 1989	No
Somalia	Yes (?)	Yes (?)	Yes (?)	No
Sudan	Yes 1998	Yes 1995	Yes 1998	Yes 1998
Syria	Yes 2001	Yes 1993	Yes 2001	Yes 1965
Tunisia	Yes 1986	Yes 1969	Yes 1990	Yes 2003
Yemen	Yes 1986	No	Yes 1983	No

As shown in Table 2, three countries (Lebanon, Kuwait and Bahrain) had in 2007 more than 30 psychiatric beds per 100,000 population, while two (Sudan and Somalia) had less than 5 per 100,000. A substantial reduction of psychiatric beds with respect to our 1998 survey 6 occurred in Iraq, Jordan, Kuwait, Libya, Oman, Qatar and Palestine.

Table 2.

Table 2 Mental health resources in Arab countries

Country	Psychiatric beds per 100,000		Psychiatrists per 100,000		Psychiatric nurses per 100,000		Psychologists per 100,000		Social workers per 100,000
	1998	2007	1998	2007	1998	2007	1998	2007	1998	2007
Algeria	14	25	1.1	2.2	1.1	4.2	0.8	0.2	0	0.4
Bahrain	33.8	33	3.7	5	13.3	23	0.5	0.8	1	1.5
Djibouti	N.A.	7	0	0	0	0.2	0	0	0	0
Egypt	12.5	13	0.9	0.9	2	2	0.3	0.4	0.09	0.1
Emirates	N.A.	14	0.9	2	N.A.	11	0.9	1	0.6	1.2
Iraq	7	6.3	0.1	0.7	0.1	0.1	N.A.	0.05	0.05	0.2
Jordan	20	15.7	1.1	1	0	2	0.2	0.6	0.5	2
Kuwait	47	34	2.6	3.1	16.2	22.5	0.9	1.4	0.4	0.4
Lebanon	47	75	1.2	2	0.9	5.03	1.9	0.6	0.6	1.5
Libya	56	10	0.3	0.2	N.A.	0.05	0.3	5	0.2	1.5
Morocco	7.6	7.8	N.A.	0.4	N.A.	2.02	N.A.	0.03	N.A.	0.007
Oman	5.5	4.9	0.2	1.4	0.2	5	0	0.2	0.1	0.5
Palestine	14.2	8.8	0.8	0.9	3.2	3.4	1.7	1	0.7	1.1
Qatar	37.9	9.7	0.8	3.4	7.4	10	1.4	1.2	1.7	10
Saudi Arabia	6.5	11.8	2.4	1.1	6.3	6.4	0.5	1	0.9	2.4
Somalia	N.A.	4	0.5	0.06	0.03	0.03	0	0	0	0.2
Sudan	0.1	2	0.2	0.09	N.A.	0.2	0.01	0.2	0.01	0.1
Syria	7.8	8	N.A.	0.5	N.A.	0.5	N.A.	0	N.A.	0
Tunisia	9.6	11.3	0.8	1.6	3.3	0.2	0.1	0.6	0	N.A.
Yemen	N.A.	18.5	0.1	0.5	N.A.	0.09	3.2	1.2	0.01	0.04
N.A. – not available

The highest number of psychiatrists is found in Qatar, Bahrain and Kuwait, while seven countries (Iraq, Libya, Morocco, Somalia, Sudan, Syria and Yemen) have less than 0.5 psychiatrists per 100,000 population. Although there is a mental hospital in Djibouti, yet there are no psychiatrists, and general practitioners with special interest in mental health look after those patients (Table 2). The number of psychiatrists decreased with respect to the 1998 survey in Libya, Saudi Arabia and Sudan, while there was a substantial increase in several other countries.

Psychiatric nurses per 100,000 population range from 23 in Bahrain and 22.5 in Emirates to 0.09 in Yemen and 0.03 in Somalia. The number of nurses increased in almost all countries compared to the 1998 survey. The same applies to psychologists and social workers, with the most substantial increase observed in Bahrain, Emirates, Jordan, Egypt, Kuwait, Libya, Saudi Arabia and Yemen (Table 2).

Recent years have seen significant changes in the field of mental health in the countries of the Arab Region. Psychiatric services, which were earlier totally confined to a few large mental hospitals, are now gradually being replaced by psychiatric units with both inpatient and outpatient facilities in general hospitals. In some countries, the process of decentralization has been taken still further, and psychiatric services are being provided at district hospitals and smaller peripheral units, along with other general health services. Training programmes in mental health for general practitioners, non-physicians and health personnel working at primary health care level have started in a large number of countries as a part of in-service skills enhancement programmes 7.

Although a majority of the countries of the region have agreed in principle to integrate mental health into the primary health care delivery system, implementation so far has been limited. Globally, the mental health infrastructure and services in most countries is grossly insufficient for the large and growing needs.

Currently, most of the Arab countries are exposed to conflicts, wars, terrorism and fundamentalism, which may be the seeds for many behavioral and mental disorders.

Cultural beliefs of possessions and the impact of sorcery or the evil eye affect interpretation of mental symptoms. In this context, the first resort for the families of mental patients is not even the general practitioner, but the traditional healers, who acquire a special importance because of their claim of dealing with the “mystical” and the “unknown”. In the majority of Arab countries there is no interaction between the medical profession and the traditional healers. In Jordan, there is some kind of a relationship, which remains informal and unorganized. In Saudi Arabia, however, they constitute part of the staff, using religious text and recitation in management.

In conclusion, our data show that, in the Arab world, health and education budget assignment is below the recommended requirements far better quality of life. The budget allowed for mental health as a percentage from the total health budget, in the few countries where information is available, is far below the range to promote mental health services. The mental health human resources and the inefficient data collection by the official agencies are incompatible with the gross domestic product of Arab countries. An appeal for implementing mental health in primary care as stipulated as a policy in many Arab countries and to prioritize mental health in the agenda of politicians is urgently needed.