Decades of violent civil war and political unrest have debilitated Afghanistan’s healthcare system and led to the populations’ exceedingly high rates of mental illness. In 2004, Afganistan’s Ministry of Public Health (MOPH) declared mental health in Afghanistan a top priority. Today, the National Strategy for Mental Health (NSMH) is taking a multifaceted approach to improving the mental health of Afgan citizens.
The National Strategy for Mental Health aims to provide a “community-based, comprehensive” system with “access to treatment and follow up of mental illness and related conditions.” One of the primary goals of this system is to integrate mental health services into Afghanistan’s Basic Package of Healthcare Services (BPHS). Within the first 10 years of mental health integration into the BPHS, 70% of patients utilizing mental health services reported “significant improvement.” Other developing countries may wish to follow Afghanistan’s lead and to begin implementing their own mental health initiatives.
Women in Taliban-controlled Areas
Mental health surveys of Afgan women in Taliban-controlled areas exemplify the link between stress and mental illness. Women living in these areas report experiencing gender segregation and violent treatment. This includes restricted employment and education as well as domestic abuse and lack of health resources.
A survey of 160 Afghan women during the 1996-2001 Taliban regime showed many Afgan women suffer from mental illness. The survey results displayed that out of the 160 women,
42% had PTSD symptoms
97% had major depression
86% had severe anxiety
Additionally, Afgan women living in Taliban-controlled areas suffered from depression at almost three times the rate of women living in non-Taliban-controlled areas (78 % versus 28 %).
Integration of Mental Health Services
In many countries, mental health support falls under general health funding, which results in very little direct funds for necessary mental health resources. However, as a result of successful integration by the Afghan government and restructuring of its healthcare system, resources for mental health in Afghanistan are available within the national healthcare infrastructure. The critical decision to absorb mental health in Afghanistan into general health has allowed mental health training to become a priority among all general physicians in addition to specialists.
The National Institute of Mental Health reports that people suffering from mental illness can potentially die anywhere from 13 to 30 years before their counterparts with no mental health problems. The integration of mental illness into general health equips primary physicians with the resources and training to diagnose and treat conditions. Transferring training and resources to primary health caregivers makes mental health services more accessible to the general public.
Afghanistan’s NSMH recognized that medication alone cannot fix mental health problems in Afghanistan. Medication treats the symptoms of trauma, not the source. This can lead to social isolation. This research led the NSMH to switch from a strictly medical treatment plan to a biopsychosocial treatment plan. This provides patients with counseling services, including stress management and domestic violence training for community health workers and teachers.
Impact of Mental Health Services
Before 2004, there were no psychiatrists working for the government. Furthermore, mental health receives less than 1% of physician training. After the integration of mental health services into the BPHS, each district hospital in Afghanistan has a full-time mental health physician who has received a two-month training in psychiatric care.
In regions that previously had no access to mental health services, there are now health facilities with health workers trained in identifying mental health disorders and creating treatment plans. These facilities can provide services for up to 60,000 people. Between 2002 and 2012, when mental health service programs were implemented, more than 900 community health workers and hundreds of doctors, nurses and midwives received training in mental health services.
Furthermore, in 2001, only 10% of the Afghan population lived within a one hour walk from a health facility. The BPHS increased the presence and accessibility of health facilities serving mental health in Afghanistan. Afterward, the overall patient visits to health facilities grew from two million to more than 44 million per year, which shows that the facilities were utilized frequently. In 2004, 22% of the health facilities served a minimum of 750 new patients per month. In 2008, 85% did.
Especially in developing countries, prioritizing mental health creates a more sustainable economy. According to the World Health Organization, depression and anxiety account for $1 trillion per year of lost or diminished output in the global economy. Additionally, when workplaces do not provide mental health resources, they lose the equivalent of 45 years of work per year. Mental health consequences on the economy and a population’s health are even greater in low-income countries due to the increased prevalence of stigmatization, superstition and treatment inaccessibility.
In addition to ethical incentives, governments have economic incentives to provide mental health services and resources because there is an economic advantage to having a healthy workforce. A failure to recognize and support populations suffering from mental health problems leads to a loss in economic productivity. Globally, every $1 that is invested in mental health disorder treatment translates to $4 in productivity and well-being.
Afghanistan’s next goal is to increase access to the BPHS for the remaining quarter of the population who still struggle to acquire health care. The growth of the BPHS and the Afghan government’s promise to expand its services to reach every citizen requires some economic input from international donors; however, the BPHS does not intend to rely on international donors forever. The World Bank, European Union and United States Agency for International Development (USAID) have been the largest donors to Afghanistan’s BPHS since the creation of the BPHS. However, each has diminished their contributions over the years.
Between 2003 and 2009, each of their individual financial contributions funded about one-third of the BPHS resources for mental health in Afghanistan. These contributions also supported technical and infrastructural support by funding construction and renovation of health facilities as well as road work projects to increase accessibility for rural populations. Between 2010 and 2012, USAID cut its contributions from $4.5 billion to $1.8 billion. Until the MOPH finds permanent funding for mental health in Afghanistan, the funding will come from donors, taxation, public spending and out of pocket pay for patients.
To fully universalize accessible and affordable mental health resources, the world, and particularly global leaders such as the United States, must continue to invest in mental health and commit to fighting poverty worldwide. Reducing global poverty reduces civil unrest, which decreases the rate of mental health problems. The World Bank, European Union and United States Agency for International Development (USAID) are the largest donors to Afghanistan’s BPHS. Continuing global support for mental health strategies helps not only poverty-stricken countries address mental health needs, but supports the global economy by increasing each populations’ well-being and productivity.
– Nye Day