Amin A. Muhammad Gadit, Memorial University of Newfoundland, amin.muhammad@med.mun.ca

Abstract

There has been an alarming increase in the incidence of mental illness the world over. Individual countries are struggling to address this issue in terms of professional resources, available facilities and economic burden. Both the developing and the developed countries are facing the dilemma under the current scenario of increasing mental health morbidity.In order to assess the situation a comparison is made between a developed and a developing country in terms of the population, number of psychiatric beds, morbidity patterns, number of psychiatrists, GDP, average annual income, health care expenditures, waiting times for consultation and nature of services. Data  related to population, number of psychiatric beds, morbidity patterns, number of psychiatrists, GDP, average annual income, health care expenditures, waiting times for consultation and nature of services was gathered systematically from literature search using PubMed, Google, Medline and publications from the W.H.O., UNICEF, Canadian Medical Association, Pakistan Medical and Dental Council, Government of Newfoundland and Labrador and local monographs for both cities in the developing and developed countries. Two cities from different worlds in terms of population, St. John’s, Canada with a significantly low population and Karachi, Pakistan where majority of the people are rural-based giving a picture of low population vs. high population. Number of psychiatric beds is much smaller compared to the population of Karachi, prevalence of mental illnesses is of higher magnitude, low average annual income, there is no established model for mental health care and general health care expenditure is from out of pocket. St. John’s has a full-fledged model with some community and specialized services, which are government sponsored, but the striking feature of this is the long waiting time hindering the health care benefits to the local population. Karachi with all its problems has practically zero to one week’s waiting time despite low number of psychiatrists. There are problems in service delivery for mental health both in the developing and the developed world and therefore, there is a room for improvement by mutual learning and modification of available resources.   

Introduction

Global scenario

Mental illness has reached an alarming proportion over the globe and has become a vitally important issue for the nations in terms of morbidity, mortality and huge economic burden. Apart from the established biological and genetic reasons, the current disruption of social fabric as a result of changing political scenario, violence and terrorism has affected the psyche of millions of individuals in this era. 450 million people in the world suffer from a   mental or behavioral disorder (W.H.O, 2003). W.H.O. “2001”, states that 33% of the years lived with disability (YLD) are due to neuropsychiatric disorders, unipolar depressive disorders alone lead to 12-13% of years lived with disability and rank as the third leading contributor to the global burden of diseases. Four of the six leading causes of years lived with disability are due to neuropsychiatric disorders like: depression, alcohol use disorder, schizophrenia and bipolar disorder. More than 150 million suffer from depression at any point in time, nearly one million commit suicides every year, 25 million suffer from schizophrenia, 38 million suffer from epilepsy and more than 90 million suffer from an alcohol or drug use disorder (World Health Report, 2001).
 

There is a world wide shortage of mental health workers both in the developing and the developed countries (W.H.O, 2003) and there are different service provision models and echoes of unmet need in the area of mental health from both parts of the world despite high economic privileges which the developed world enjoy. The authors has worked extensively in both parts of the world and have observed the unmet needs of similar magnitude. In order to gain insight into this state, a review was made between two countries: Canada from the developed world and Pakistan from the developing world. In order to be more focal: Karachi which the largest city of Pakistan and St. John’s, the capital city of Newfoundland and Labrador has been selected for comparative analysis. Author has worked for ten years as a consultant psychiatrist in Karachi and is currently working in St. John’s.

Pakistan: Background information

Pakistan is the 9^th populous country in the world, though area wise it ranks thirty-fourth among the thirty-seven low-income countries. It is the fourth most populous country after Bangladesh, China and India. It has total population of 157,935000, GDP per capita(intl $ 2004) 2,151, life expectancy at birth m/f : 62/63, infant mortality : 102/1000, total health expenditure per capita (intl $ 2003): 48, total expenditure as % of GDP (W.H.O., 2005): 2.4, GNI per capita is $600, urban population: 34%, literacy rate: 49%, population below poverty line: 35% (UNICEF, 2006), total number of physicians is 128073 which includes 18, 633 specialists (P.M.D.C., 2006). The total number of psychiatrists is 250 for such a large population is a grossly small number (Table 2). There are 125 psychiatric nurses, 480 psychologists, 600  social workers and the number of alternate practitioners is about 12,000. The magnitude of mental illness is: 6% depression, 1.5% schizophrenia, 1% Alzheimer’s disease, 1-2% epilepsy and the other disorders (Gadit & Khalid, 2002). There are government run psychiatric facilities in general hospitals which cater for a very nominal fee ($ 0.50), the private sector which charges $ 10-20 and other non-governmental charitable services which in most of the cases would cater for free. The related health expenditures are based on out-of-pocket expenses.

Karachi

Karachi is the largest city of Pakistan and a former capital. It is now the capital of the province of Sindh. It is a cosmopolitan city, with a population of about 14 million. The number of psychiatrists practicing in Karachi is around 44. Magnitude of mental illness in Sindh is: depression: urban/rural 16%/12%, schizophrenia: urban/rural 2%/1.5%, psychosomatic disorders: urban/rural 5%/7%, seizure disorder: urban/rural 1%/2%, substance use disorder: urban/rural 7%/6.5%, obsessive-compulsive disorder: urban/rural 2%/1%. The total number of psychiatric beds in government/private sectors is 184 (Gadit & Khalid, 2002).

Canada

The developed countries enjoy a much better state of development indicators and are capable of providing their citizens with much better facilities in areas like civic amenities, health care facilities and protection of life and property. Among the 25 top countries in this regard, Canada occupies 10^th position. It is considered as the best country to live in and is a perfect welfare state. The population of the country is: 31958000, life expectancy at birth is 80, urban population is 81%, GNI per capita $ 28390, infant mortality rate: 5/1000 (UNICEF, 2006), total number of physicians: 66,583 (Table 2). The total number of psychiatrists (C.M.A., 2006): 4142 and the magnitude of mental illnesses is: One-year prevalence: major depression-4.1-4.6%, bipolar: 0.2-0.6%, dysthymia: 0.8-3.1%, schizophrenia: 0.3%, anxiety disorder; 12.2%   (Health Canada, 2002). The number of other mental health professionals are: psychologists: 14,695, psychiatric nurses: 5,121, social workers: 28,689, the number of alternate practitioners dealing with mental health is unknown.

St. John’s, Newfoundland and Labrador

The provincial population is 514,409, GDP: $ 23,985 million, personal income per capita: $ 25,872, land area 405,720 km square, 58% of the population is urban, 42% of the population is rural, total number of psychiatrists : 60, available psychiatric beds : 202 (H.C.C., 2004). There is a strong network of mental health services in the province with major concentration in St. John’s, the capital city. The morbidity pattern is almost similar to that of the country as a whole. The services are supported by the government and the consumers get the benefit of state sponsorship through the medicare plan.  Though the services are structured and in line with the global model of mental health care, the waiting lists are long. An average waiting time for the psychiatric patient to be seen is varying from 3-12 months (Personal Communication).

Methods

Data such as population, number of psychiatric beds, morbidity patterns, number of psychiatrists, GDP, average annual income, health care expenditures, waiting times for consultation and nature of services was gathered systematically from literature search using PubMed, Google search, Medline and publications from a W.H.O., UNICEF, Canadian Medical Association, Pakistan Medical and Dental Council, Government of Newfoundland and Labrador and local monographs.  The information gathered was arranged in order to compare the situations in both the set ups. Selection of both these cities was based on the author’s work exposure with a view of finding some similarities and differences in each system and possibility of mutual learning and subsequent improvements.

Results

Two cities from different worlds in terms of population, St. John’s, Canada with a significantly low population (58/42, U/R %) and Karachi, Pakistan where majority of the people are rural-based (34/56, U/R %) giving a picture of low population vs. high population in total. Number of psychiatric beds is much smaller (Karachi: 184, St. John’s: 202) compared to the population of Karachi, prevalence of mental illnesses is of higher magnitude (Karachi: Major depression: 6%, Bipolar disorder: 1%, Dysthymia: 9%, Schizophrenia: 1.5%, Anxiety Neurosis: 3% vs. St. John’s: Major depression: 4.1-4.6%, Bipolar Disorder: 0.2-0.6%, Dysthymia: 0.6-3.1%, Schizophrenia: 0.3%, Anxiety Neurosis: 12.2%), number of psychiatrists (Karachi: 44, St. John’s: 60), low average annual income (Karachi: $600 per annum, St. John’s: $ 25, 872 per annum), there is no established model for mental health care and general health care expenditure is from out of pocket (Karachi: out of pocket health expenditures, St. John’s: Medical Care Plan).  St. John’s has a full-fledged model with some community and specialized services, which are government sponsored, but the striking feature of this is the long waiting time ( 3 months -1 year) hindering the health care benefits to the local population. Karachi with all its problems has practically zero to one week’s waiting time.  

The results were tabulated and are being presented in the form of a table which is hereunder:

Table 1:

Comparison between  Karachi (Pakistan) and St. John’s (Canada)

Table: 2  
Comparison of vital information between a developing country (Pakistan) and a developed country (Canada)

                                                      PAKISTAN                                        CANADA

Discussion

The table1 depicts contrast between two cities from different worlds, St. John’s in a developed nation and Karachi in a developing nation. The number of psychiatric beds is much smaller compared to the population of Karachi, prevalence of mental illnesses is of higher magnitude as compared to that of St. John’s, this can be explained on the basis of low awareness about mental illnesses, different cultural beliefs and low literacy, also, there is low average annual income, no established model for mental health care and general health care expenditure is from out of pocket. The cultural factors are of importance in diagnosis, seeking of health care and management. In Pakistan, the general belief system of a large number of population is based on influence of evil eye, possession, evil influence and witchcraft. Hence, most of the people especially from rural areas would seek help from shamans and alternate practitioners or in some cases will approach a family practitioner.

Only 5% of the mentally ill patients would come to the attention of a psychiatrist (Gadit, A & Reed, V. 2004). Though the vocabulary of expression of symptoms is different depending upon language and cultural background, yet, they are diagnosed on the basis of ICD-10 or DSM-IV criteria. Treatment of psychiatric disorders is given by psychiatrists or family practitioners themselves but a number of patients also see an alternate practitioner of mental health. In Canada, there some variation in presentation especially when a patient belong to an aboriginal community or immigrants coming from various countries bringing in with them their cultural characteristics, yet, they are assessed on the basis of DSM-IV criteria are followed up mostly by the psychiatrists and family practitioners. Few patients also take alternate therapies along with their current medications. The number of beds in St. John’s 202 for a population of 250,000 as compared to that of Karachi which has 184 beds for a population of 14, 000,000 which is explained on the basis of under developed psychiatric services in Pakistan and low priority to this discipline by the government. The annual high income in St. John’s is based on the general economy of Canada which is on a higher rank among the developed countries. St. John’s has a full-fledged model with some community and specialized services, which are government sponsored.

The full fledged model is based on mental health services with tiers like initial contact with family practitioners, if needed, referral to specialized services provided by psychiatrists with the multidisciplinary team. There is availability of psychotherapy services, early psychosis program, psychiatric rehabilitation, long tern and geriatric services, child and adolescent service, addiction programs, day programs and effective social services. In Pakistan, it is mainly the adult general psychiatry which is practiced; the other specialties are scant and under developed. The striking feature despite good service model in Canada is the long waiting time. Karachi with all its problems has practically zero to one week’s waiting time, in the face of low number of psychiatrists, alternate practitioners flourish because of the tremendous faith invested in their services by local population because of low literacy level. It is transpired that despite the affluence and established services, the people in St. John’s do not get urgent and quick services when needed. The only option that remains is that of ending up in the emergency department with some on site services. 

The problems of shortage of nursing staff and psychiatrists are often voiced and hence most of the patients are seen by family practitioners.  Interestingly, both the countries are having different climatic conditions, the mental health morbidity is somewhat higher in Pakistan than Canada but it does not appear in the current study that difference could be due to the weather conditions. There are reports of higher prevalence of depression in cold climate countries and high anxiety neurosis in warm countries but the trends in this study  may be not be attributed to this solely. The collections of statistical data in Pakistan are not systematic and scientific as there are some flaws in system and record keeping. The information management systems dealing with health statistics are not well developed. The figures are collected individually from departments and sent to statistics department of the government. The information management system in Canada works efficiently and managed through CIHI-Canada. (www.cihi.ca).

Lessons to Learn

For St. John’s: Psychiatrists should see more patients in a day. The old concept of seeing eight patients a day is no longer feasible. There are a number of patients who are stable and should need either brief consultation or can be referred back to family practitioners for ongoing follow up. Community based psychiatry should be further developed and utilization of day hospital services will cut down the admission rates and reduce the burden of health care services. Introduction of voluntary services by psychiatrists for walk in and needy patients is another option worth considering. More incentives for psychiatrists in terms of an attractive package at par with other provinces, at least, at par with the province of New Brunswick. Provision of full license based on satisfactory assessment by the College of Physicians and Surgeons of Newfoundland & Labrador in line with that of New Brunswick. The Government should consider lowering the tax table in line with the province of Alberta keeping in view the growing economy of the province.

For Karachi: The mental health services should be defined in a structured way. There is a need for conducive environment for psychiatrists in view of disturbed political scenario. Aversion of brain drain of psychiatrists is possible by providing attractive remuneration and development of a proper service structure. At federal government level, there is a need to introduce a medical coverage plan like that of Medical Care Plan in Newfoundland. Rising of awareness and improvement in literacy level will go a long way in bringing down the morbidity pattern of mental illness.

Conclusion

Despite better health care planning and relatively developed mental health model, St. John’s (Canada) has so far failed to address the problem with long waiting lists. However, the Medical Care Plan is a great facility for the population. Karachi which has a large population with low average annual income has the great disadvantage of paying through out of pocket for the health services. This is a huge economic burden for the population. The good aspect is fast availability of services despite smaller number of psychiatrists. There is a need for cutting down the waiting time for patients in St. John’s by increasing the number of consultations by the individual psychiatrists and by appointing and retaining the psychiatrists in the system. This can be done by improvement in the incentives for psychiatrists, development of more community psychiatric services and by utilization of day hospital services. For Karachi, it is imperative to define the mental health model with the introduction of specialized services. There is also a need for providing conducive environment for the psychiatrists, offering them better incentives and adopt measures which could address the brain drain. There is also a need for government sponsored health care plan in view of low average income of the population. It appears that many developing and developed countries if compared like this would present more or less the same picture. However, more studies like this are needed in order to develop further understanding of different systems in both worlds.         

Suggestions

For Pakistan, it is important that the government should take appropriate steps towards promotion of mental health by taking certain steps like: Introduction of a comprehensive package for mental health education, better career structure for psychiatrists and allied mental health professionals, implement the new health policy in true spirits, allocate more funds for mental health services, improvement in rural psychiatric services and follow the WHO guidelines while framing policies.

For Canada, it is important for the government to improve the policy which can help in retention of more locally produced mental health professionals, allowing the foreign trained psychiatrists to get full license based on a period of distinguished service, develop the community based psychiatry in such a way that it could cut down admissions and also the waiting lists, develop priority list for efficient services in areas of need.  

References

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W.H.O. Human resources and training in mental health, 2005, p: 2-11, Geneva, Switzerland.

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