Improving mental healthcare in Pakistan
While mental health is high on the health care agendas of developed countries, Pakistan lags far behind. Poor government funding, scarce professional resources and the underreporting of cases associated with negative stigma are impairing development.
Trained mental health care providers and facilities for the almost 208 million population are scarce, with around 300 psychiatrists and very few qualified mental health nurses. According to the World Health Organization only 0.4% of the total healthcare budget is allocated to mental health services in Pakistan, institutional care is custodial, and families bear the burden of care for their loved ones.
This means there is approximately one psychiatrist for every 10,000 people, and the ratio of child psychiatrists to children is one to four million. Many of the staff who are available are auxiliary staff and the number of trained mental health professionals, particularly nurses, in unknown.
The Aga Khan University (AKU) is a not-for-profit private university that contributes to the healthcare services of the region by improving the quality of education through human resource development, institutional capacity building and research. In achieving its mission, AKU operates on the core principles of quality, relevance, impact and access.
The AKU School of Nursing and Midwifery (SONAM), is the leader of nursing education, research and clinical developments across Pakistan. Its work has raised the image of nurses pursuing professional careers, and strengthened the healthcare system.
Mental health is one of the priority areas for SONAM: The BSc Nursing curriculum at prepares graduates for entry level mental health in various settings, while an Masters in Nursing programme with an Advanced Practice Nursing stream in mental health is planned to commence in 2019.
The SONAM Mental Health Clinical Stream is an inter-professional team working to strengthen education, services and research in the field, and contribute to the capacity building of nurses to strengthen the mental health services in their respective institutions at the national and regional level.
Karwan-e-Hayat: a case study of nurse-initiated growth in mental health care
One local a non-profit organisation, Karwan-e-Hayat (KEH), established in-patient services in 2005. To provide support to strengthen their services AKU-SONAM has built a collaboration with KEH focusing on four key areas: infrastructure, capacity building, standardisation of services and collaborative research.
SONAM worked with the KEH technical team to develop an infrastructure and milieu for the inpatient setting that was therapeutic and culturally acceptable. This was supported by visits to AKU psychiatric services to introduce the team to the best available facilities in Pakistan.
Another major role that AKU-SONAM performed was to build the capacity of the care providers to strengthen the mental health services offered. AKU-SONAM provided advice to assist in standardising affordable and accessible quality of care to clients.
Initially, auxiliary staff were hired when the facility was established, and the concept of therapeutic care was overlooked in favour of a more custodial approach, in keeping with the stigmatised view of mental illness at the time. This invited a challenge in terms of developing the capacity of staff to adopt the essential knowledge and skills needed to work with people with mental health problems.
Addressing stigmatised attitudes and discrimination were central to ensure empathic and compassionate care was provided to the clients. Periodic training sessions were conducted by AKU-SONAM including the basic concepts of mental health nursing that align with the mental health curriculum approved by the national regulatory body.
Since 2005 several SONAM graduates have moved to work at KEH, providing leadership and therapeutic direction. Continuing education is regularly provided to support standardised care through role-modelling by faculty members, some of whom practice clinically and also supervise the undergraduate students during their mental health nursing rotation. KEH staff participate in the SONAM Stream meetings where continuing education plans, the guidelines for nursing assessment, care and its documentation have been developed.
To sustain the standards of care and staff development at KEH, graduates with leadership abilities and a foundation in mental health care were selected to join and in 2015: one former student was appointed as assistant nursing manager and the other as patient care coordinator.
These two alumni were also supported through mentorship to bring about positive changes, including improvements in milieu therapy, patient physical and hygiene care, engagement in activities in the in-patient setting, improved hiring procedures for staff, improved nurse patient ratios, patient care assignment and staff allocations, as well as a structured staff development plan.
In 2018 a faculty practice and research collaboration commenced, whereby nurse-led patient case management was initiated under the mentorship of a KEH consultant and an AKU mental health nursing expert.
This has improved one-to-one patient management and, importantly, included family members in the care process. Research activities to identify relevant and contextual solutions to mental health issues, and to develop evidence-based nursing led projects are currently under way.
In an environment where government mental health services are sadly lacking, and where qualified mental health nurses are a rarity, a partnership between two not-for-profit organisations, one a university, the other a residential and outpatient mental health facility, a credible health care service has grown through the innovations and dedication of the faculty of AKU-SONAM and staff of KEH.
The result is a mental health care service of a quality rare in Pakistan which is struggling to cope with an increasing population with growing mental health issues, not unlike that of the developed world.
INSPIRE (Jan 30, 2013). Internationalizing Higher Education. http://ihe-pakistan.blogspot.com/2013/01/recognising-mental-health-issues-in.html