WHO- ~ / M R N T / 1 13- rt March 1986

INTERCOUNTRY MEETING ON NATIONAL PROGRAMMES OF MENTAL HEALTH

Damascus, Syrian Arab Republic, 2--6 November 1985

(Meeting Reference: EM/INC.~~~G.NAT.PMH/~)

VORLD HEALTH ORGAN1 ZRT LON REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN

1986

The issue of this document does not constitute formal publication.

The manuscript has only been modified to the extent necessary for proper comprehension. The views expressed, however, do not necessarily reflect the official policy of the World Health Organization.

The desisnations employed and the presentation of the msterial in this document do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the aelimitation of its frontiers or boundaries.

TABLE OF CONTWTS

................. 2 . REVIEW OF PROGRESS OF MENTAL HEALTH ACTIVITIES 2

................................................ 3 . COUNTRY REPORTS 4

4 . AN OVERVIEW OF THE PROGRESS I N KENTAL HEALTH I N THE EASTERN MEDITERKANEAN REGION ............................... 12

............ . 5 nEVELOPMENT OF NATIONAL PROG-S OF m T A L HEALTH 15

............................ . 6 DEVELOPNENT OF MENTAL HEALTH I N PHC 2 0

................................................. . 7 SPECIAL TOPICS 27

.................................................... 8 . CONCLUSIONS 29

................................................ 9 . R C C O ~ D A T I O N S 30

ANNEX I AGENDA ................................................... 33

....................................... ANNEX I I L I S T O F PARTICIPANTS

....................... .....,... A..NEX I I I L I S T O F B A S I C DOCUMENTS .. 38

............................. ANNEX I V L 1 S . O . BACKGROUND DOCUMENTS 39

1. INTRODUCTION

An intercountry meeting on national programmes of mental health was held in Damascus, Syrian Arab Republic, from 2-6 November 1985. It was attended bv participants from seventeen M-mber Etates in the Eastern Mediterranean Region and concerned WHO staff members. The list of participants is given in Annex XI.

The intercountry meeting w a s a part of the series of the Regional Coordi- nating Group beetings which are held once every two years. The purpose of these meetings is to bring together top country experts dealing with mental h ~ a l t h prnerammes and to obtain their advice on WHO collaborative activities in the Region. Based on the reconmendations of the last intercountry mee~ing held in Amman, Jordan, in September 1983, and the Global Coordinating Group nieeting held in Washington DC, USA, in December 1983, it was decided that the present meeting should be largely devoted to problems related to the dcvelop- ment of national programmes of mental health.

The objeccives of this meeting were:

- To review the progress of activities in the field of mental health in the countries of the Region.

- To recommend guidelines for early development of national programmes of mental health.

- To recommend suitable strategies for the development of mental health services at the primary health care (PHC) level.

- To promote the knowledge and application of behavioural sciences in the development of health systems.

1.1 Opening of the meeting

The meeting was opened by H.E. Dr C. El Rifai, Minister of Health. Govern- ment of Syrian Arab Republic. Dr Rifai in his address mentioned that mental illness is being recognized as a major health problem and spoke of the steps taken by his Government to ensure provision of comprehensive health careofor the mentally ill, in close collaboration with other concerned agencies, e.g. the Ministries of Social Works, Labour and Education. . He added that attention is also being paid to the preventive aspects of mental illness.

Dr tiussein A. Gezairy, Regional Director, Eastern Mediterranean Region of IJHO,in his message of welcome to this meeting, pointed out that the majority of mental health problems receive inadequate or no attention. Hc emphasized the need to develop national programmes of mental health which should include the aim of extending the delivery of health care for the mentally ill within rxis~ing hralth services, using the PHC approach. Dr C e ~ a i r y also referred to the growing psychosocial problems especially drug abuse, and urged partici- pants to develop strategies for this growing threat.

1.2 Election of officers

The following participants served as officers during this meeting:

Chairman: Dr Yarsein Mouftah (Syrian Arab Republic) - vice-chairman: Dr Hassab El Rasoul Suleiman (Sudan) Rapporteur: Dr M.H. Mubbashar (Pakistan)

1.3 The proposed agenda and proprarme of work were adopted, with minor modi- fications. The adopted agenda is given in Annex I.

2 . REVIEW OF PROGRESS OF MENTAL HEALTH ACTIVITIES

In preparation for the intercountry meeting, all country representatives had boon invited to prepare n progress report for their respective countries. These reports focused specifically on the health policy and mental health care structure and developments in the two years since the last intercountry meeting (Aman 1983). These reports were included as working papers. Both '

individually and collectively, they provide an understanding of mental health care in the countries of the Region. The following section begin8 with a global review of progress in the field of mental health. This is followd by a brief report of the experience of community mental health from the South- East Asia Region. The country reports highlight recent developments and aspects relevant to country mental health prograrmnes. An overview of develop- ments in the Region summarizes the salient points of the regional mental health situation.

2.1 Global tema and developments

Mental well-being is an essential element of health and Health For All by the year 2000 (HFAf2000) cannot be achieved unless mental health is given appropriate attention. This means that promotion of mental health must be included in efforts to promote health in general and that prevention and control of mental, neurological and psychosocial problems should be given higher priority in national programmes chan is now the case in many countries.

The frightening magnitude of the task has now become well known. Some 300 million people in the world are suffering from one or another type of problems in this area. Of these, some 40 million are suffering from psychoses and related conditions. An estimated 25 nillion suffer from epilepsy. Alcohol and drug dependence are now ravaninn younger age groups. Medicine is seen as becoming dehumanized. Measures to promote socio-economic development are often taken without regard to the psychology of people.

Fortunately, however, important prospects have been opened up for mental health programmes in recent years. Significant new knowledge has become avail- able, helping the understanding of mental functioning as well as the causation and parhogenesis of menral and n e u r u l ~ ~ i ~ a l illnesses. Operational research

i n both developing and developed count r ies has brought forward evidence t h a t a s i g n i f i c a n t propor t ion of a l l contac ts i n PHC has t o do with psychosocial problems and f a c t o r s . I t has a l s o been e s t ab l i shed i n a number of s t u d i e s done dur ing the l a s t t en years t h a t many mental and neurologica l d i so rde r s can be competently handled i n primary and o ther genera l h e a l t h ca re s e r v i c e s . I [ : has beer1 blruwr~ tha t the motivat ion of genera l hctrlrh workers and the quality

of t h e i r work can be s i g n i f i c a n t l y a f fec ted by techniques o f f e red bybehavioura l sc iences . The p o s s i b i l i t y of s t imu la t ing community p a r t i c i p a t i o n i n hea l th programmes, using psychosocial approaches, has been demonstrated. The need f o r and the b e n e f i t s of i n t e r s e c t o r a l cooperat ion i n the development and implementation of mental hea l th programmes has been amply confirmed i n a number of s e t t i n g s .

These f indings ga in f u r t h e r s ign i f i cance i n t h e l i g h t of the f a c t t h a t a number of coun t r i e s have introduced mental h e a l t h elements i n t o PHC and t h a t t h i s has led t o b e t t e r s e rv i ce ro rhe popularion and murr >atisfaction of those providing i t , ye t without a s i g n i f i c a n t i nc rease i n cos t f o r ca re . Mental hea l th programmes need no longer occupy the p lace of an experimental programme; the techniques now ava i l ab le and the experience obtained together form a comprehensive technology package ready f o r a p p l i c a t i o n on a broad s c a l e .

I n a number of coun t r i e s h e a l t h dec is ionlnakers a r e s t i l l n e i t h e r aware of t he s i z e of mental , neurologica l and psychosocial problems nor of t he p o s s i b i l i t i e s t o prevent o r con t ro l them. As a consequence, mental h e a l t h i n these coun t r i e s has s t i l l not become a component of n a t i o n a l s t r a t e g i e s f o r HFA/2000. I n o the r coun t r i e s , s i g n i f i c a n t changes have occurred and s t rong na t iona l h e a l t h programmes have come i n t o ex i s t ence . On occasion these have s t a r t e d with a sharp focus on s p e c i f i c problem, e .g . drug dependence. I n o ther s i ruac ions , a more comprel~ensive model of programmes has developed, in- cluding promotive, prevent ive and cu ra t ive e f f o r t s , and adopting a broad scope, including mental and neurologica l problems, a lcohol and drug dependence and t h e promotion of h e a l t h f u l behav iour . Psychosocial a spec t s of h e a l t h care and o v e r a l l development have a l s o been given s p e c i f i c a t t e n t i o n i n such programmes.

There has been a continuous inc rease of the r ecogn i t ion of t he need t o ca r ry out mental h e a l t h p rog rames i n a m u l t i s e c t o r a l mode, a c t i v e l y involving a number of s o c i a l s e c t o r s such a s h e a l t h educat ion , wel fare , the i n t e r i o r , defence and planning. In some s e t t i n g s , mental h e a l t h p ro fes s iona l s were ne i the r prepared nor w i l l i n g t o accept t l ~ e s e new chal lenges and con~ i r tu rd to concent ra te on the provis ion of care t o p a t i e n t s with psychoses and o the r severe d i so rde r s . This on occasion meant t h a t important o p p o r t u n i t i e s f o r rhe development of comprehensive p rog ramcs have been missed.

I n a number of r eg ions , smal le r groups of coun t r i e s have come together t o d e a l with h e a l t h problems. This tendency has a l s o a f f e c t e d mental h e a l t h programmes. Count r ies i n South-East Asia (ASEAN) i n South East Af r i ca (Africa Mental Health Action Group, AMHAG) and La t in America (Andean group) a r e examples of groups of coun t r i e s among whom programmes of t echn ica l cooperat ion in mental h e a l t h have come i n t o e x i s t e n c e .

2 . 2 Experience from another Regiz

The South-East Asia Regional countries share similarities in terms of limited specialist manpower, institutional facilities and economic background. rht, d c v c l c ~ p m r n t s in thc oren of ory:lnizing community mental health services ~n the last few years from SEARO was considered by the group. The most notable progress has been made in the area of developing country mental health pro~rammes. India (~opulation 750 million) initiated pilot projects to in- tegrate mental health as part of PHC as early as 1975. In the subsequent ten years, the two pilot projects at Chandigarh and Bangalore have been en- larged to include a dozen centres involving population units of 50 000 to 1.5 million. Specific manuals of mental health care for medical officers and ~aramedical workers have been produced. Regular training programmes of two weeks for medical officers and one week for paramedical personnel have been produced and have become roucine. OLher countries of the Region to develop such programmes are Bangladesh, Indonesia, Thailand and Sri Lanka. Two countries, namely Bangladesh and India, have developed time-bound country mental health programmcs with the objectives of ensuring nvailability of mini- mum mental health care for all, encouraging application of mental health know- ledge in general health care and enhancing community ~articipation in mental hfalth services development. In some of the countries of the Region (SEAR) mental health component is included in PHC manuals. In addition, specific

mental health manuals for different categories of PHC personnel have been cli.\.cloped both in English and in local languages. Another significant deve- lspment is the research interest taken by mental health professionals in issues relating to mental health care at PHC level. Particularly notable among these is the WHO/SEARO collaborative research study on recognition and management of psychosocial problems by PHC physicians. The developments in SEAR offer opportunities of exchange of experience as well as collaborative efforts in training mental health professionals and PHC personnel.

3. COUNTRY REPORTS

Summaries of the country reports presented at the meeting are given below:

Afghanistan - -- Mental Health care in Afghanistan until recently consisted only of the

custody in the capital, Kab~ll, of 50 long-stay patients. There were no Other facilities, plalls UL legislation. Rclotivcs wore left to cope w i t h

the gravely ill.

Now there is not only a mental health section in the central administrative office of the University but there is an multisectoral advisory "Higher Central Council of Mental Health" under the President of the Council of Ministries. There is a plan for development of the psychiatric services. It is aimed to integrate mental health care with the public health services in the country.

There h a s been a seriol~s i nc rease i n the abuse of n a r c o t i c s i n t h e country and a drug dependency survey is planned f o r Kabul, I t i s hoped t h a c UNFDAC w i l l support t h i s t o provide information f o r an app rop r i a t e response.

The mental hea l th s e r v i c e i n Bahrain s t a r t e d i n 1932 with a "Lunatic Hotlse" which became the "Lunatic Asylual". In 1947 it became parr of t h e medical department and a p s y c h i a t r i c nurse was appointed. A doctor was appointed i n t h e f i f t i e s and a p s y c h i a t r i s t i n 1967 who in t roduced modern p s y c h i a t r i c t r e a t m e n t and opened an out-patient c l i n i c i n t h e gene ra l h o s p i t a l . A post-basic nurse t r a i n i n g course was s t a r t e d i n 1981.

Thcrc are now fn13r p s y c h i a t r i s t s (one i n c h i l d p s y c h i a t r y ) , 160 nu r se s and o t h e r s t a f f . The 180 beds a r e h a l f - f i l l e d wi th long-term p a t i e n t s . Tllr I n s t i t u t e f o r Retarted and Handicapped Children and t h e Juven i l e Delinquent Cpntre a r e wel l -es tab l i shed .

The community p s y c h i a t r i c s e r v i c e and team were s e t up i n 1 9 7 7 , based on the h o s p i t a l . A compaign aimed a t educa t ing the community i n t h e problems of drugs , supported by a s p e c i a l c l i n i c and a 12-bed u n i t , was followed by a f a l l i n t h e number of drug-dependent p a t i e n t s .

Ir: is plarined to integrate mental haal th ca re w i th PHC. Post-graduate p s y c h i a t r i c medical t r a i n i n g and courses a r e he ld f o r o t h e r h e a l t h c a r e s t a f f . The r e s i d e n t t r a i n e e s conduct r e sea rch and a r e encouraged t o pub l i sh t h e i r r c o u l t s .

Mental h e a l t h s e r v i c e s a r e c u r r e n t l y being d e l i v e r e d through the Athalnssa

I n s t i t u t i o n , p s y c h i a t r i c wings a t General Hosp i t a l s i n Nicosia and Limassol, o u t p a t i e n t departments , a community s e r v i c e and v i s i t s t o p r i s o n s , c o u r t s and t h e Welfare Department.

Plans e x i s t for d e c e n t r a l i z a t i o n and upgrading of t he s e r v i c e s . Tra in ing i s provided fvr prepregistrotion doctnrs, nurses and h e a l t h v i s i t o r s . Three hundred e l d e r l y people a r e cared f o r i n t h e i r own homes by persons pa id by the Government. Soc ia l workers monitor progress and he lp r e s o l v e s p e c i a l problems.

Democratic Yemen

Before 1966 when the f i r s t mental h e a l t h s e r v i c e w a s e s t a b l i s h e d mental p a t i e n t s were kept i n Aden pr i son . This s e r v i c e comprised a c losed mental h o s p i t a l of 100 beds. A new p s y c h i a t r i c h o s p i t a l of 220 beds was due t o be opened i n 1985 . Menral h e a l c l ~ care i s frcc for the 2 000 000 i n h a b i t a n t s of Democratic Yemen.

For the fuLu~r, decentlalization of the scrviceo nnd eventual integration of mental health care with PHC are planned. Mental health training is provided for medical officers and nursing staff. WHO has assisted in the planning of provision of essential drtl~q and is supporting a workshop to be held in 1986 to promote a national policy of mental health.

Egypt has a long association with WHO in the field of mental health. In 1970 a WHO seminar on psychiatric medical education emphasized learning to care for the patient as a whole person physically, mentally and socially. The Fayoum project, begun in 1978, is part of WHO world-wide extension of mental health services to rural areas.

There are seven mental hospitals with 6332 beds and 19 general hospitals with a total of 621 beds. Clinics exist for health insurees, schools and university facal l t ie+ . The aim is to include special group needs, e.g. chil- dren and the aged, and to be multidisciplinary. Mental health professionals may offer help and advice to all care-givers in helping with the emotional problems of patients.

Mosques and voluntary organizations have given strong support to recent developments in the mental health services in all mental hospitals and out- patient psychiatric clinics, especially ro combat drug abuse.

The Director-General of Mental Health in the Ministry of Health leads the implementation of thc national comprehensive m e n t a l health plan. Decentrali- zation of the mental health services and integration with PHC has been imple- mented. Training at all levels is available, i.e. for undergraduates, pqyrhintry post-graduates, other medical officers and other health care staff as well as care-givers in the comunity. Training is also available for workers from other countries.

Islnmic Republic of Iran

fiental health care for the 40 million people of the Islamic Republic of Iran has to be seen against a background of mauy social problems, the shortage of trained manpower in all areas, the remoteness of many village populations and limitations of the public health services.

There are 36 psychiatric facilities in the country. Fifteen are in Teheran. Seven are university-based and the remainder under the Ministry of Health. There are 200 psychiatrists in the country. The Ministry of Health's development of the services is aided by the newly-formed Teheran Psychiatric Institute and the Iranian Psychiatric Association. Work has begun on an attempt to include a mental health component in the proposed national network of health services and the revision of the medical educational system.

1)ecentralization of mental health services has been widely implemented and it is planned to include mental health at PHC level.

Training in m'-n*al health care is available at the levels of under- : r ~ s psychiatric specialist trainees, medlcal officers, ocher heal~h c ~ r c stnff and other care-givers.

i<cllgiot~s leaders have ~ w d e important contributions to the preventive and rehabilitative care of those affected by the serious problems of narcotic drug dependence.

IJHO assistance has contributed to defining the scope of mental health problems, services and training. Two current research projects are in the arcas of mental health problems of war refugees and the epidemiology of scl~i zopl~renia.

Jordan

The mental health services in Jordan consist of two civil hospitals with 390 beds, the Royal Medical Services unit of 40 beds and a university unit of 2 0 beds. There is one day centre and one rehabilitation centre. There are 11 psychiatrists and 19 postgraduate psychiatric trainees (at home and abroad) in these facilities. Thirteen psychiatrists work in the private sector. There are 11 nurses and 12 other trained staff in government service.

The multisectoral National Consultative Cormnittee for Mental Health is working to prepare a national programme and establish a national mental health centre. The latter will be a base for training, service and research.

A policy of decentralization of mental health care to general hospitals is being implemented, and a three-month craining programme for students of internal medicine is available. Epilepsy and mental retardation are major public health problems which have not received adequate attention. Although drug abuse is not a major problem in Jordan, detoxification facilities are being planned by the Ministry of Health.

Community involvement in the use of volunteers in hospitals, community contacts in employing ex-patients, and providing them with money, clothes and recreation, have all helped to reduce the stigma of mental illness.

A psychiatric special committee is reviewing the Jordan Mental Health A L L .

A 'linisrry of Justice special committee is planning amendments to the sections relevant to mental health in the Jordan Criminal Law, the Jordan Civil Law and t h e .lordan Law of Court Procedures.

The o f f i c i a l mental h e a l t h s t r a t e g y and plan were adopted i n 1982, a l though implementation has not y e t been achieved. The p o l i c y of decen- t r a l i z a t i o n has been i n i t i a t e d by p rov i s ion of e i g h t r e g i o n a l p s y c h i a t r i c o u t p a t i e n t c l i n i c s . I n t e g r a t i o n of mental h e a l t h i n t o PHC is planned. A four-week p r o g r a m e of t r a i n i n g f o r PHC phys ic ians i s a v a i l a b l e .

Over a number of years 20-24 p a t i e n t s have been taken on a p i lg r image t o tfecca. A doc to r and nurses accompanied them. A formal e v a l u a t i o n of t h e psychologica l and p s y c h i a r r i c bene f i c i s planned f o r 1983.

Lebanon

I n t h e p a s t y e a r s t he p s y c h i a t r i c i n s t i t u t i o n s of Lebanon have r ece ived p a t i e n t s from a l l surrounding c o u n t r i e s . The p s y c h i a t r i c Hosp i t a l of t h e Cross was a p ioneer i n t h e u se of chlorpromazine, I n the past. most p ~ y - c h i a t r i c i n i t i a t i v e came from t h e p r i v a t e a r e a ye t h a l f t h e h o s p i t a l beds a r e occupied by p s y c h i a t r i c p a t i e n t s .

'The c u r r e n t emphasis on t r a i n i n g i nc ludes s e n s i t i z i n g medical s t u d e n t s t o mental h e a l t h problems by a two-month t r a i n i n g course i n t h e f o u r t h yea r . Pos tgradua te t r a i n i n g i nc ludes f o u r y e a r s of i n t e n s i v e t h e o r e t i c a l and c l i n i - cal training a t psychiatr ic IIospital of the Cross. General prac t i t i oners and gene ra l nu r se s r e c e i v e two t o t h r e e months' t r a i n i n g .

Community involvement i nc ludes t h e a c t i v i t i e s o f t h e Church i n response t o t he major n a t i o n a l problem of drug dependency.

Libyan Arab Jamahi r iya

The f i r s t p s y c h i a t r i c f a c i l i t y i n Libyan Arab Jamahi r iya was a t r a d i t i o n a l h o s p i t a l a t A 1 Marj A 1 Kadim which was des t royed by an ear thquake i n t h e sixties, leaving only the p s y c h i a t r i c h o s p i r a l i n ~ r i p o l i . Menral illness was s t i l l s u f f e r i n g from nega t ive p u b l i c a t t i t u d e s .

The A1 Fateh Revolution in 1969 paid great attention to general and p s y c h i a t r i c h e a l t h s e r v i c e s . S p e c i a l i s t s and nu r se s were r e c r u i t e d from Egypt and t h e Sudan. In 1974 a p s y c h i a t r i c h o s p i t a l o f 200 beds was e s t ab - l i s h e d a t Dar A1 S h i f a . A new h o s p i t a l of 250 beds was b u i l t i n t h e e a r l y 1980s. This i nc ludes a h o s p i t a l , a mosque and a farm f o r t h e r e h a b i l i t a t i o n of p a t i e n t s .

Emphasis i s being g iven t o mental h e a l t h t r a i n i n g a t undergradua te l e v e l , t o gene ra l p r a c t i t i o n e r s and t o s t u d e n t s of psychology, educa t i on and s o c i a l s t u d i e s . V i s i t i n g p r o f e s s o r s f rom o t h e r c o u n t r i e s f o r m a t each ing r e sou rce .

Cornunity involvement includes contributions from both relatives and the mosque.

A research project into the effects of ECr is being carried out.

A t the time ol independence, P d k i a ~ a r r lcad t h r e e mental h o s p i t a l s . Ilciwever, these were in poor condition, with little treatment available and f e w trained staff.

Even today, 702 of the population living in rural areas have few psychia- tric Eacilities and seek mental health care from hakims (traditional practi- tionern) and homeopaths.

There are mental health hospitals at Hyderabad, Lahore, Dodhiol and Peshawar. There are also psychiatric units in 16 university teaching hospitals and psychiatrists have been appointed to some districc hospi~al>.

Although it is the agreed policy to integrate mental health care at PHC level, this has yec co be achieved. However, the Sixth Five-vear Plan aims at the integration of mental health services, including the treatment of priority mental disorders, as an essential component of PHC. A multidisci- plinary workshop was scheduled to he h e l d in December 1985 to promote this development. Decentralization is already being implemented by the increasing numbers of psychiatrists appoined to general hospitals.

Mental health training for undergraduates, psychiatric speciallsts and other medic-? iractitioners is available. Curricula for PHC workers are being prepared and religious and community leaders are being trained in crisis intervention.

Heroin addiction is a grave and recent problem. The estimated 1 300 000 rc;:r?Iar drug abusers come from all groups in the community. The Government's rcsponse is directed by the Pakistan Narcotics Control Board and includes the esinblishment of 26 treatment and rehabilitation centres. There 'as been c a c m t r y - w i d e training of general practitioners and social workers. Religious lcnders and others in the community play an active part in prevention.

The mental health legislation has been reviewed by an multisectoral expert connnittee and is currently awaiting final approval of the author~tles concerrtcd

Saudi Arabia

Until 1983 mentsl health care in Saudi Arabia was mainly provided by Taif Yental Hospital. This meant that patients had to be sent long distances and the Ilospital, designcd for 400 patients, contained 1800 in 1978.

\,IIO-E?I/YENT/ 1 13-E page 10

Ten psychiatric l~uspitals of 30-80 beds and 20 outpatient clinics have now been developed.

A mental health dir~rtnr has heen appointed in the Ministry of Health. I)eccntralization has been implemented and integration of mental health into lJ l lC is planned.

Training is available for undergraduates, postgraduates up to the national diploma in psychological medicine, for medical officers, mental health nurses. psychologists and social workers. Many expatriates also benefit from this training. ~arcotic drug dependence ranains a serious aroblem.

Somalia has a long tradition of tolerance and an understanding approach to mental health problems with reassurance, prayers and blessings. The in- troduction of influencps frnm outside the country resulted in the Forlanini Mental Asylum being established in 1955. The poor standard of care originally provided in this hospital has been improved in recent years, but continues to give a misleading impression of modern psychiatric care. Mental hospitals, each of 60 beds, have been established at Hargeisa and Berbera.

The Government has decided to establish a mental health unit in the Ministry of Health for planning, coordination, ir~~plernentation and evaluation of tile mental health services in the country. It has now been appreciated that large mental hospitals will not solve the problem and small psychiatric units in general hospitals should be established instead.

Courses have been organized for nurses, MCH supervisors and PHC teachers. Khat-rh~wing was a serious problem and in 1983 a law was passed making import- ing, growing, keeping and chewing khat illegal and punishable.

Sudan

Psychiatry in the Sudan began in the fifties under the guidance of the laLe Professor Tigani El Mahi, "father of African psychiatry". He pioneered, among other things, rural services and the open-door policy. His successor. Dr T.A. Baasher, shouldered the responsibility and further extended the services to the periphery. He established the Mental Health Association of Sudan and thc Sudoncse hssociation of P~ychiatrists. Dr Hassabo Suleiman and Professor S.I. Abdel Rahim continued mental health development in establishing a Psychiatric Medical Assistants School as well as training courses for social workers and psychologists, to provide for Sudan and other countries. Sudan played an important role in WHO studies for extending mental health into PHC.

There is a general directorate of Mental Health in the Ministry of Health Headquarters. There is also a National Advisory Council and National Plan and Policy for mental health. Decentralization to district general hospitals occurred in the early sixties and has now been implemented in PHC.

Training courses are available for undergraduates, psychiatric specialist trainees, medical officers, other health care staff and other care-givers. The most recent development is a postgraduate course for the DPM @iploma of Psychological Medirine).Doctors from other countries attend for training.

Tntensive community involvement includes use of the mosque and input from religious healers as well as the Sudanese National Society of Mental Health and the Sudanese Institute of Traditional Medicine.

Narcotic drug dependence represents a recent serious problem in Khartoum. Measures to combat this are direcred by L I I ~ ~eultidisciplinar~ Sudanese Natinnal Narcotic Control Board, with support from WHO.

Mental health research in Sudan has a long history, including collaboration with WHO and other bodies in a study of schizophrenia diagnosis, child problems and community studies, e.g. the Kalakla project. Mental health legislation forms a chapter of the Public Health Act of 1973. This was reviewed by the Sudanese Psychiatric Association in 1985.

Syrian Arab Republic

Psychiatric services in Syrian Arab Republic have been given attention only in the last ten years under the guidance of the corrective movement. The movement emphasizes a citizen's bodily and mental health, and thus leads to greater efficiency and optimum productivity.

A specialized department for mental health has been established in the central administration of the Ministry of Health. This is to draft a national plan for mental health after the WHO workshop in 1986. Trends in mental health policies comprise decentralization, integration and provision of essential drugs. It is hoped to have 6-10 beds in the general hospitals of the main towns.

In order to provide manpower for these emerging facilities it is planned to have training prograrmnes for doctors and nurses.

It is the Government's intention to have special centres for alcohol and drug abusers, child psychia~ry alld psychosocial intervention.

Following independence in 1956 there have been great efforts towards develop- ment in Tunisia. The country has a population of seven million. Major migration to the cities has altered family structures, ~ h ' e oldest and largest mental hospital, the Razi Hospita1,was founded in 1931. There is a 40-bed unit aK El Omrane. There are 26 qualified psychiatrists and the same number in training.

A mental health director has been appointed to the Ministry of Health. The Tunisian Socicty for Psvchiatry is preparing plans for a national organi- L I f I I I I L ~ I ! I I . I i ~ i training and research. The i~i;t.;hlislrmt~nt of t w o l > s y r i , i . i t r i L wnrris o f 189 beds has tostered decen~raliza- t ion .

Yemen has expcrienced very rapid development during the last two decades, which has transformed social classes. A serious problem is that 1.2 million of the 8.5 million population work abroad. Before the Revolution. the mentally ill were attended by traditional healers, or else imprisoned or became vagrants. After the Revolution. however, the beginnings of modern mental heilth care emerged, in the form of intermittent outpatient clinics, and in 1981-1982 was firmly introduced.

A Mental Health Directorate in the Ministry of Health was ser up in 1985, and a National Mental Health Plan was drawn up for 1984-1985. There is decen- tralization, with a commitment to integration of mental health care into PHC.

Mental health training is available in the ~nstitute of Medical Manpower, for nurses, general practitioners and other health care staff. Community involvement is intensive, throuah sor ia l cooperatives and voluntary societies.

Special problems include the effects of migration, traditional patterns of marriage. and khat-chewing. The C.overnment is encouraging the replacement of khat plantations with coffee and other crops.

WHO has been providing technical collaboration for the mental health programme since 1981. The University of Sana'a has recencly established a research centre and there are projects on various aspects of mental health, in- cluding "Khat and mental health".

Innovations include the use of part of a prison as a mental hospital, the involvement of relatives in patient care and adoption of the "open door principle" in the r n e n t n l hospital.

4 . AN OVERVIEW O F THE PROGRESS IN MEKTAL HEALTH IN THE EASTERN MEDITERRANEAN REGION

. : , . . . 1t is obvious from a review of the country reports that significant changes

are taking place in the countries of the Region in the field of mental health. The stigma regarding mental illness is diminishing and people are more openly coming forward for treatmentto modern psychiatric services. In a number of countries, for example, Egypt, Saudi Arabia, and Sudan, there is now a separate senior o f f i c r r III tlle Ministry of llealth designated to look after the mental health activities in the country. Although most of the countries still do not !~nve a specific national mental health policy, some, such as Democratic Yemen and Sonialia, have already plared mental health on their list of health priorities.

The ocher significan~ devrlupstrnt during the last dccodc i~ that psychiatric services, which were earlier totally confined to a few large mental hospitals, are now gradually being decentralized. Psychiatric units with both inpatient and outpatient facilities. have started functioning in many general hospitals in the large cities, in manv countries of the Region, for csample, in Cyprus, Ejivpt, I r a n , Pakistnn.Sltdan and Svrian Arnh Rcpuhlic, and more recently in Democratic Yemen, Somalia and Yemen. In some countries, . Cyprus, Democratic Yemen, Egypt and Sudan, the process of decentral~zatlon has been taken still further and psychiatric services are being provided at district hospitals and smaller peripheral units, along with other general health services. Although many countries have agreed i r ~ p~inciple that mental health should be incorporated into the PHC delivery system, so far there has been only limited implementation, in two countries, namely Egypt and Sudan. tlowevrr, a significant dcvclopment may be seen in the training programmes in mental health for general ~hysicians, which have started in a large number of countries. A review of these training programmes suggests that, so far, most of them are not specifically geared to the needs of PHC. These training programmes are generally oriented toward imparting the latest knowledge in psychiatry rather than concentrating on teaching essential practical skills to general ~hysicians so that they can look after a large number of patients with mental, neurological and psychological problems who currently attend the health services at the PHC level. Recognizing the shortage of mental health pro- fessionals and even of general physicians, some countries e.g. Egypt, Sudan and, more recently, Democratic Yemen, have started ~urntal health training

- programmes for non-physicians and health personnel working at PHC level. Democratic Yemen has also introduced the programme of essential drugs for the neuropsychiatric services. This has greatly reduced cost and initial reports suggest more satisfaction with the services.

The review of the country reports has also highlighted some serious barriers in the implementation of the mental health programmes. The shortage of qualified mental health professionals in almost all the countries of the Region is well-known. For example, facilities for training leading on to a postgraduate qualification in psychiatry are available only Ln a small number of countries such as Egypt, Islamic Republic of Iran, Pakistan, and, to a limited extent, Jordan and Saudi Arabia. Sudan also has very good facilities a n d i t is abouc ro start i ~ b p ~ > t g t d L i ~ ~ a t e training programme in psychiatry. Islamic Republic of Iran has recently upgraded its facilities by establishing the central Teheran Psychiatric Institute. Among the Arabic-speaking countries o f the Region training faciliti~c fn r rliniral psychology are at present limited only to Egypt while psychiatric nursing training is available in Bahrain and

Egypt.

One additional problem which is being faced in many countries is the lack of clarity of the role of various members of the mental health team, i.e. psychiatrists, clinical psychologists, social workers, nurses, etc. Many mental health professionals received their initial training in the Western industrialized countries and often transfer prejudices and interprofessional

IWO-E~~/PIF.P;T/ 113-E page 14

rivalries from there to developing countries. To extend the mental health services, particularly in the context of PHC in developing countries, it is important that these rivalries be quickly contained so that the total potential contribution of each professional group is integrated into the broader national prograrmnes for menLal health. It was also nored ~ l ~ d t . while training programmes in mental health for in-service doctors have started in many countries, the teaching of mental health and behavioural sciences in the ,inder<raduatc. medical curriculum continues to be inadequate. This situation needs speedy correction.

One o t h e r s t r i k i n g f a c t which emerged from the review of the country reports was the negative attitude toward mental health which is often en- countered among health planners and administrators. This stzms mainly from lack of knowledge about recent developments in the field of mental health. For example, a large number of health administrators are still not aware that mental illness and psychosocial problems are very frequent in developing countries and a large proportion of disability in the community is produced by them. Furthermore, it is possible now to adequately treat and manage, and perhaps also to prevent, many of these conditions at an economical cost. n~is, however, can only be possible if mental health services are integrated with general health services and not encouraged to grow as separate. specialist- oriented programmes which ultimately end by providing services only for a limited number of dwellers in large cities.

Another stumbling block in the provision of mental health services is the existence of old and outdated mental health legislation in some countries of the Region which makes it difficult for many needy persons to utilize available services. Some countries, such as Pakistan and Sudan, are taking active steps to improve such legislation. The poor condition of records in the present mental health services in some countries was also pointed out by many participants as a serious shortcoming, hampering the development of national programmes of mental health. It was also observed that a good records and information system would be essential for starting some action- oriented research in tlre countries of the Region. It was stressed that, currently, there is very little collaboration between university departments and ministries of health in the implementation of mental health progranunes. This situation needs to be improved.

Whilst surveying mental health problems of more recent origin in the Region many participants referred to the existence of international conflicts and their effects on large sections of the population. Also the periodic migration of large numbers of mostly the adult male population was identified as a serious stress factor in many countries. However, it was generally agreed that one of the most disturbing new mental health problems emerging in many countries is the rising trend of drug abuse among youth. While it was appreciated that drug abuse is a complex social problem, involving many sectors, and that often the solu~iuns do ilut lie i n the health ficld, nevertheless, the mental health services have the primary responsibility of tackling the health-related problems associated with drug dependence.

W~~O-EYIPIENT~ 11 3 -E page 15

The country reports were also noteworthy in in recording many innovative approaches which some colleagues have introduced in their countries in order to cope, with limited resources, with the very difficult problems concerning mental health. Often these innovations go unrloLicrd or are merely considered routine maccers in a given couucry. I . ~ l r cxilrnple, t h e practice o f r r d m i t t i n f i a relative along with the patient in a psychiatric. inpatient service in a general or mental hospital is currently practised in many countries of the Region, e.g. Libyan Arab Jamahiriya, Pakistan. Sudan, Yemen. etc. This is an improvement in service from the mental health point of view and it is a practical step in view of the limited number of nurses and other staff. How- ever, this approach is quite different from that traditionally practised in mental health services in Western countries. Among the other innovative approaches, one can also mention the use of the Mosque, and other religious institutions, for cornunity involvement which is taking place in Egypt, Saudi Arabia and many other countries. This is particularly in~po'tant in tackling the problem of drug dependence. Another interesting approach was seen in Yemen, where until recently there was no mental hospital and the problem was approached by converting part of a prison into an open hospital for mental patients.

In conclusion, it would appear that in the field of mental health develop- ment, the last decade has been highly significant. Although limitations of resources, particularly in the field of qualified manpower, continue to be a serious constraint, a new phase in mental health services in the Region has been launched, with the emphasis on decentralization of services, integration of mental health with general health services and organization of training programmes in mental health for general physicians and other health personnel working at PHC level. The time is now ripe for these individual efforts and fragmented activities to be organized into comprehensive national mental health programmes, incorporating not only elements of prevention and treatment but also the promotion of mental health as a logical step towards HFAl2000.

5. DEVELOPMENT OF NATIONAL PROGRAMMES OF MENTAL HEALTH

As has been observed in the previous chapter, the cliaate for mental health in the countries of the Region is changing and many new mental health activities have started. In the,opinion of the group, it is very important that at this juncture these activities be coordinated into nacional programmes of mental health at country level.

5.1 m e need for national programmes of mental health

Development of national programmes is important for the following reasons:

(a) All countries of the Region have already developed national strategies for HFAf2000. However, in most of these national documents mental health is not included in spite of its recognized importance. There is, there- fore, urgent need to correct this omission so as to include mental health activities in country health strategies and plans.

1,~io-i.~::~xXT/ll3-E

page 16

(b) ?'he scarcity of human and often of material resources increases the need for their careful ~~tilization. The present fragmented activities in the field of mental health cnn he coordinated and consolidated only if therc is a national proRrammP o f mental health involving various sectors of national activi;ies.

( ) Opportunities for intrncountry 3 s well as intercountry technical coopera- tion wi>uld grentlv in:prnv.. - i r i . ; l ~ e emergence of specific plans of action for mental health at country level.

(d) The existence of national mental health programmes would facilitate the acquisition of extrabudgetary resources to support country programmes.

5.2 Components of naLio11a1 yrogrames of mental hcolth

The components of a country mental health programme include:

- promotion of mental health - prevention of mental disorders - treatment of the mentally ill - improvement of functioning of the general health services - contributions to overall socio-economic development, and - enhancing the quality of life.

Promotion of mental health calls for an awareness of mental health as one oi the components in the scale of values in the lives of people. Such an awareness would bring this need into focus, in all matters affecting people's lives, be they economic, social or political. Such an awareness has to be at the level of individuals, communities and societies.

Prevention of a significant proportion of mental, neurological and psycho- social problems is now possihle: it has been estimated that at least half of all such disorders in developing countries could be prevented. Many preventive methods are simple, effective and of low cost. Much preventive work will have to be done by general health services and through the intervention of other sectors. For example: (i) provision of iodized salt to pregnant women in areas of iodine deficiency prevents nnenc:il retardation; (ii) early (and appropriate) stimulation of the child and the discovery and correction of any sensory deficit (e.g. poor sight, hearing) can both significantly decrease the numbers of children labelled as "mentnlly retarded" and improve their functioning; (iii) crisis intervention (e.g, support to the recently bereaved) brings with it significant health benefits, a n d iiv) cerebrovascular disorders can be reduced by control of hypertension.

Indeed, treatment of the mentally ill is now both possible and practicable. The common misconceptions that mental illness is not common, does not form a burden, and cannot be treated, that interventions are expensive and require highly trained personnel, and that PHC personnel do not have a role in the care of the mentally ill, have to be corrected. Models of care that are both

IJ~~(?-.cM/MI.:KT/ 1 13-E

page 27

inexpengive and effective are currently available. Moreover, it has been shown in a number of countries that non-specialists can become the backbone of the care programme.

Tllc current prac t i r e c ~ f mct? ic inr i r l ::,any? L . o t ~ l ~ t ~ 3 i r., is over-relianr: on t t c i ~ n o l o g y . Psychosocial skll l s whlch could render the health care worker more efficient and more satisfied with his/her work ate not taught in most countries. 'Ihe population's s a c i s f a c t i v ~ ~ w i ~ l ~ l jeal th care is dccrcocing, in spite of in- creased expenditure on health service provision. Mental health disciplines can provide the knowledge and skills necessary to overcome these problems: it is t h e task of mental health progrnnnnes ensure that this is done.

Similarly, but on a different plane, socio-economic development often leads to situations of major psychosocial impact. Untoward consequences of develop- mental projects can often be avoided; comprehensive mental health programmes should contain the capacity to collaborate with those responsible for planning and economic development and provide knowledge which may render social change and development more harmonlous wl th the expectarfons and psycilulugical needs of people. All these tasks of mental health programmes require collaboration between various social sectors and different disciplines. More importantly, however, chey require a change in the perception of mental health programmes by both the population and the decision-makers and a change in attitude of pro- fessionals and others dealing with the design and implementation of the programmes. If the value attached to mental health is high the motivation to undertake measures to prevent and treat mental illness will be high, cornunity participa- tion in such programmes can be expected and societal support for appropriate programmes will be forthcoming.

5.3 Steps for development of national programmes of mental health .

Development or national programmes of health essentially means translating a policy into a plan of action. There are a number of steps which are involved in this process.

h policy provides broad guidelines and framework for action. Policy stems from the basic principles governing the country as contained in the country's r n n s r i t r ~ t i n n , international agreements and codes of behaviour, A national policy can be understood from a number of sources such as (i) legislation affect- ing the general public; (ii) previous activities to promote health; (iii) prog- rammes of other social sectors; (iv) religious and other teachings relevant to health and well-being; (v) current health practices; and (vi) the harmony berweerl existing policies and the programmes of the various social sectors.

Strategy refers co che way resources will be utilized. A programnre includes activities directed toward certain goals. A plan of action outlines the parts of the programme for implementation. A project is the operational unit of t h c programme.

The above forms the operational basis for developing a national programme of mental health.

WHO-E?/?EMT/ 113-~ page 18

5 . 4 Development of a plan of action at national level

5 . 6 . 1 How to start a national programme of mental health?

The initiative for a national programme can come from political level, from health administrators or from strong public opinion. Mental health professionals can influence it at each level and are generally responsible for its start; they can help to start the process by promoting an awareness of the need for a plan of action, by lobbying with political authority, health planners and administrators, by l l ~ v b i l i z i n ~ opinion through the press, TV and other media and by organizing national mental health groups incorporating all related sectors.

Once enough momentum has been generated, it should he crystallized into a nucleus, i.e. a mental health action group entrusted with the task of developing an initial outline and draft national plan. Such a draft needs t o be reviewed at successive stages by mental health professionals, health admini- strators and planners, experts of other sectors such as social service, educa- tion, law, non-governmental organizations, university research bodies, etc. and finally adopted by the Ministry of Health in full or in pares as rhe plan of action.

5 . 4 . 2 Drafcing a national pla~i uf action

It has already been emphasized that a national programme of mental hcnlth should include all componpnts o f mental health as noted in section 5-2. Given below is a brief outline of items which can be useful while preparing a plan of action for mental health services. A draft plan of action should cover the following areas:

A) The current mental health situation in the country

Data on mental illness, rncluding results of prevalence and incidence surveys, if available, and annual statistics from mental and general hospitals. An assessment of existing resources, i.e. hospitals beds, uldnpuwer, number of psychiatrists, doctors, nurses, social workers, psychologists, etc. Existing training facilities, including medical schools, health institutions, specialist training facilities, etc. Current cnvPraEe by the listed services as well as remaining gaps and the needs in special areas such as child mental health, mental retarda- tion, school health, drug dependence groups, elderly ill, criminal mentally ill, vagrants.

B) Objectives of the programme

Objectives of the programme must be identified. For exaelple, one objective could be the provision of minimum mental health care for all. Another objective could be to enhance community participation and self-help in mental health programmes or to encourage wider appliration of mental health knowledge and skills for psychosocial problems.

WHO-EMINENTI113-E page 19

C) Strategies and approaches

General guiding principles should be: to integrate basic mental health services; to provide vide coverage of population; to deliver mental health service in the PHC setting by non-specialists; appropriate training in mental health fur health personnel at all levels in order to carry out appropriate tasks; provision of an adequate referral system; strengthening of specialist services; provision of essential drugs1 intersectoral collaboration; and linkage with comunitv development.

D) ~e~ail.3 of activities

The draft should fix both short- and long-term targets and especially list artivities planned to be carried out in the next 3-5 years. These activities should focus particularly on various aspects of training and service.

E) Coordination

For coordination it is important to develop some mechanisms. For example, ir: will be useful to have a fnral point in the Ministry of Health and the National Advisory Committee incorporating top health administrators and mental health specialists, with representation of oL11er sectors.

G) Financial implications

The cost estimate should include expenses on: national workshops; meetings of advisory group; trainins! of manpower through short training courses for immediate needs; training of trainers; strenr thening of existing specialist cadres and institutions: provision of essential drugs; and administrative expenses.

H) Monitoring and evaluation

The mechanisms for monitoring and evaluation should be built into the draft of the programme.

5.5 Barriers to development of national proerames of mental health

Following the discussions on the general principles and guidelines for formulatine. national programmes of mental health, the participants divided into four groups. These groups focused attention on the applicability of the national mental health prcgrannne in Lllrir countrice and identified barriers to its development. The final task of the group was to suggest methods of overcoming these barriers.

I.ltl0-E?l/%NT/113-E paae 20

The barriels identified were; (i) organieational, (ii) professional, (iii) developmental and (iv) barriers related to PHC care. Organizational barriers comprise (a) lack of appreciation by the policy-makers and senior health adm~nistrators of the nature and extent of mental illness in the commu- nit\: (b) l a c k of a focal point resnonsihle for mental health in the ministries of health; ( c ) absence of reference to mental health in national policies, and (d) non-inclusion of mental health in the list of health priorities. Pro- fessional barriers comprise: (a) shortage of fully or well-trained psychratrlsts, clinical psychologists, psychiatric social workers and nurses; (b) low prestige of psychiatry as a specialitv; (c) mental health professionals working Dre- dominantly in institutional settings and not supportive of the national programme and (d) lack of public-health,community-oriented mental health professionals. Developmental barriers comprise (a) resource constraints in terms of money and teclr~lical inputs; (b) limited funds available for the health sector. and ( c )

lack of a supportive welfare structure for the total care of the mentally ill. Barriers at PHC level include: (a) non-inclusion of mental health in the rl;rrirula of various rate~ories of health personnel; (b) general lack of resources for the care of the mentally ill as reflected in the non-availability of essential drugs; (c) lack of a data base on mental health problems at PHC level, and (d) poor intersectoral coordination at the periphery.

The group made several recommendations to overcome some of the barriers identified above; these are included in the list of recornendations (see section 8).

6. DEVELOPMENT OF MENTAL HEALTH IN PHC

Prlmary health care (PHC) is essentially health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the communities and countries can afford. It forms an integral part of the country's health system of which it is the nucleus and of the overall social and economic development of the country (WHO 1978). The new approach in PHC requires that mental health programmes utilize all existing resources in the health structure as well as in the community. It also means the development of mental health services in harmony with the health and social policies of the countries.

An essential feature of PHC is the provision of services closest to the pcoplc by appropriatc lcvcls of health personnel. In order that they provide mental health care, it is a necessary first step to understand the role and work patterns of the existing health personnel. This should be followed by identifying the tasks/roles to be undertaken by the different health personnel, keeping in mind the national systems of support and supervision. Training has to be provided to all primary health care personnel (doctor, health assistant, midwife, etc..) as they all have to function as a team and complement each other's work. Another important aspect is to conceptualize mental health in promotive, preventive and curative dimensions, as the ongoing PHC activities

WHO-EM/MENT/ 1 U-E page 21

allow for three components of mcntal health care, These aspects of PHC and integration of mental health principles into PHC require that each country will have to develop appropriate task decisions and training programmes. In planning task decisions it is essential that the morbidity patterns that are prevalent in the country as well as the significant connnunity concerns should be given importance.

Mental health knowledge for health administrarors

Health administrators play a vital role in the development of mental health care at PBC level. Currently, they have limited understanding of all the components of a mental health programme (5.2). There is need to plan activities specifically so as to enhance their awareness, bring about changes in ac~itudes and mobiliee their support. Information channelled to health administrators becomes effective when it is provided in the light of the following points: (1) information should be provided at an appropriate time f o r programne planning: ( 2 ) information should be provided as part of the broader community concern and not in an isolated manner; (3) information should be clear and conveyed in acmprehensible manner; (4) information should be provided to decision-makers and others simultaneously, and (5) information should be given about issues upon which action is possible. Active and con-

tinuous effort should be exerted to develop a dialogue with health administrators at all levels. Periodic review of the. progress jointly is also necessary so that health administrarors come Lo consider mental health as part of the larger community need. Availability of field practice areas, epidemiological data, training manuals and a plan of action for implementation can stimulate their active support.

6.2 Roles c'f mental health professionals

The traditional roles of mental health professionals and these in other related disciplines are being redefined to meet changing needs. The new PHC approach opens up new needs and roles for all PHC professionals. Moreover, advances in mental health knowledge demand the active involvement of different professionals in a flexible manner. The shortage of manpower requires the optimal utilization of all available professionals groups. It is important that in the new PHC set-up various profescional groups develop harmonious relationships and mutually supporting roles, with the conanon goal of mental health care for all in the community. In some countries in the EM Region, e . g . Sorn01~0, nurses are playing an important leadership role which needs to be further recognized and strengthened. Similarly, there is great potential for psychologists and social workers in the mental health programme in many countries of the Region, However, it is important to remember that these roles cannot be rigidly outlined; they .should be reviewed periodically and efforts be directed to build up team work for mental health care programmes.

!,JHO-EM/!U?NT/ 113-E page 22

6 . 3 Training programme for general physicians

There are serious inadequacies in the amount of undergraduate training in mental health in the countries of the Region. The new approach for integration of mental health with PHC requires training to be provided to the PHC physicians. Such training programmes should include not only curative asperrs of mental health but all the other components outlined above.

A number of countries have recently started special training programmes for general physicians. These training courses should help not only to improve the knowledge of and attitude toward mental health but should provide special skills to manage day-to-day mental health problems. Skills of listening, talking to patients, eliciting evidence of psychopathology and providing emotional support must be incorporated into these training programmes. It is suggested that nearly half the training period should be devoted to practical work with patients and communities. Experience has shown that training i s best carriod out in settings vpry plnse to the routine place of work of the physicians. Sufficient emphasis should be placed on the use of psychotropic drugs in order to encourage their optimal use and prevent their abuse. Training should be such that the trainees learn the practical manage- ment of problems seen in PHC.

Based on the experience gained in recent years, it was felt that as far as possible the subjects listed hereunder should be covered in each training course. Depending on the availability of time, some topics can be reduced or additional ones added:

Health policy and plans of the country, including health structure at PHC level Brood classification of mental disnrAers Epilepsy and common organic disorders Psychotic disorders Depression and affective disorders Drug dependence and alcohol Common and important neurotic disorders (including sexual disorders) Common psychosocial problems seen in PHC Common childhood disorders and mental retardation Counselling and supportive psychotherapy Prevention and rehabilitation of mental and neurological disorders EssruLial p~yclrotro~ic drugs Mental health legislation and referral facilities in the community

Experience of t r a i n i n g nnn-sp~rialist physicians was reported by a number of countries of the Region. The duration of training has ranged from one to four weeks. The group noted that there cannot be a uniform method to meet the differing needs of the countries of the Region, e.g. duratlon of training, topics to be included, manuals required, etc. It is important that, as part of the training, emphasis be placed on the existing national health and mental health policies and the PHC structure of the country. It has been found from I

WO-EY/MENT/ 113-E page 23

experience chat raining manualo should be prepared tn a n s i s t t h e phys ic ians dur ing t r a i n i n g and subsequently a l l t r a i n i n g p rog rames should be eva lua ted both f o r t h e i r short-term and long-term impact, Short-term evaluation can b e done by uoing pre- and pos t - t r a in ing eva lua t ion of knowledge and d i agnos t i c s k i l l s .

Long-term e v a l u a t i o n would r e q u i r e v i s i t s t o p l aces of work t o a s s e s s t h e type of mental h e a l t h ca re provided. Such pos t - t r a in ing and un-the-jab eva lua t ion would al low f o r modi f ica t ion of the programme, making i t more s u i t - able and e £ f e c t i v e . The group a l s o recognized t h e need t o develop a simple classificatory system f o r use a t PHC l e v e l ,

6 . 4 Train ing programmes f o r o the r h e a l t h personnel

The PHC s t r u c t u r e inc ludes a wide v a r i e t y of h e a l t h personnel such a s community h e a l t h workers, medical a s s i s t a n t s , nurs ing s t a f f and h e a l t h cducntors. Currrntly t h e above personnel have well-defined h e a l t h r e s p o n s i b i l i t i e s which do no t i nc lude mental h e a l t h . It i s recognized t h a t a number of a c r i v i - t i e s undertaken by t h e s e h e a l t h personnel have p reven t ive and promotive mental h e a l t h e f f e c t s . An example i s t h e adequate p rov i s ion o f maternal and c h i l d h e a l t h s e r v i c e s which can prevent a l a r g e amount of mental handicap. Thus the

r o l e of h e a l t h personnel i s complementary t o t h a t of phys ic ians .

The d e c ~ s i o n about cask div~ritution would depend on educa t iona l back- ground, popu la t i on covered, l e g a l p rov i s ions and a v a i l a b l e day-to-day support and superv is ion . A t e n t a t i v e l i s t of t a s k s i s o u t l i n e d i n p p 42/23 of t h e rapurt of the In t e r coun t ry Meeting nn Mental Heal th. Amman, 1983. Tra in ing programmes should be organized i n t h e PHC s e t t i n g r a t h e r t han a t t h e l a r g e r teaching h o s p i t a l s . The t eache r s should inc lude t h e superv isory s t a f f a long with s p e c i a l i s t s . Spec i f i c manuals should be made a v a i l a b l e t o each ca tegory of s t a f f wrth c l e a r l y o u t l i n e d aims and r e f e r r a l p a t t e r n s . The d u r a t i o n of t r a i n i n g can va ry b u t experience h a s shown t h a t an i n i t i a l t r a i n i n g of about 40 hours , spread over one o r two weeks, i s adequate. A l l t r a i n i n g p rog rames should be eva lua ted , an both a sho r t - and long-term basis. It would b e

advantageous i f t h e t r a i n i n g programmes were t o be organized i n p l aces where a mental h e a l t h programme is a l r eady i n progress .

Frovision o f an adequate referral system i s an e s s e n t i a l component of mental h e a l t h c a r e i n PHC. To enable t h e PHC personnel t o f u n c t i o n adequate ly i t i s important t o provide good support and back-up facilities. These can be f o r t h e management of cond i t i ons f o r which PHC s t a f f ha s no t been t r a i n e d o r problems f o r which t h e r e a r e no adequate resources a t PHC l e v e l . I n a d d ~ t i o n , a r e f e r r a l system works a s a method of cont inuing educat ion. I n view of t h i s , t h e r e f e r r a l system should be b u i l t i n a planned manner a s p a r t of t h e o v e r a l l programme. Experience has shown t h a t t h e r e i s need Fur the specialice to be a v a i l a b l e on a r e g u l a r b a s i s p e r i o d i c a l l y f o r advice , S imi l a r ly , some form of shor t - s tay h o s p i t a l i z a t i o n should be b u i l t i n along t h e cha in of the support system.

WHO-EM/)IENT/ 113-E page 24

Maintenance of simple and longitudinal records allows for supervision of the work at all levels. However, it is recognized that the referral system should be flexible and should not lead to delays in treatment for patients. In the EM Region, differing patterns of referral system are functioning, from a highly organized one in Democratic Yemen and Fayoum Governorate, in Egypt, to an open system in other countries. It was recognized that there is need to study in detail the suitability of various referral systems for the countries of the Region.

6 . 6 Provision of essential drugs

Over 80 countries in the world have now adopted a national list of essen- tial drugs. The main advantages of using a limited range of essential drugs are: a reduction in the number of drugs to purchased, stored, analysed and dis- tributed, resulting in a more effective management and quality control; better possibilities of block purchasing and consequently lower prices, and better possibilities lor comprehensive and objec~ivr drug information.

In the WHO model list of essential drugs six anti-epileptic and six psycho- therapeutic drugs have been included. In WHO/EMRO list of essential drugs for physicians in PHC, three anti-epileptic drugs and three psychotherapeutic drugs are included. In the WHO/EMRO list of essential drugs for the community health worker none of these drugs are mentioned at present. The constant availability of a few essential drugs is an essential requirement for any basic mental health care at the peripheral level. A list of the essential drugs for neuropsychiatric disorders at each level of health care is outlined in Table 1. Experience r lob ally and in the Region (for example. in Democratic Yemen and Egypt) has shown that it is possible to identify a limited range of drugs for use at the different levels of mental health care. In the EM Region, research efforts should be directed towards the dosages to be used and the duration of treatment.

The group also considered the question of inclusion of drugs under the Psychotropic Convention. For example, it was.pointed out that phenobarbitone offers an effective and inexpensive way of treating grand-mal epilepsy. However, inclusion of this drug under category IV of the Psychotropic Convention limits its wider availability in PHC settings. The Expert Cormnittee of WHO was requested to reconsider the position of phenobarbitone in the light of the needs and experience of developing countries.

6.7 Information systems

An essential component of the decentralized mental health care programme is the provision of records at all levels. Mental health records should be ( i ) simple to use, (ii) a p p r u p r i a ~ r Lo ~lle level of health staff. (iii) aimed towards clearly defined goals, and (iv) regularly analysed, with feedback provided to the health staff. Sufficient attention should be paid to the confidentiality of the records of the patients. Hospital level data should be linked with PHC data and reviewed to see how they can be utilized for national health programme formulation in addition to service needs.

NHO-EM/MENT/113-E page 25

,rable 1 Consolidated l i s t of e s s e n t i a l drugs f o r mental h e a l t h c a r e

* Not on t h e WHO Model L i s t of Essen t i a l Drugs, 1983 1

6.8 Ind ica to r s

1

Spec. Hasp

phenobarb. phenytoln diazepam i n j . e thosuxi- mide carbama- zepine v a l p r o i c ac .

chlorprom. ch lo rp r i n j . a m i t r i p t y l . diazepam fluphen i n j ha lope r ido l l i t h i u m ca r . t imipramhe)* (benzatropl*

Ind ica to r s have t o be u t i l i z e d f o r t he purpose o t monitoring s r ~ v i c e programmes. Such information may r e l a t e t o t h e number of persons suffering from d i f f e r e n t mental d i s o r d e r s , t he po in t of con tac t , t he r e g u l a r i t y of t reatment and burden of t he menta l ly ill on t t ie fami ly and community. I n d ~ c a t o r s

f o r country programme development a r e : formulat ion of mental hea l th po l i cy , frequency of concern expressed by both nubl ic and p o l i t i c i a n s i n l e g i s l a t i v e t O I - U m S and Khe p r e s s , lncreasc i n t r a i n e d n a t i o n a l s to manage t h e n a t i o n a l mental h e a l t h progrannne, number of workshops on community ca re of t h e mental ly ill and e x t e n t of r ev i sed mental h e a l t h laws. A f u l l d i scuss ion on t h e sub jec t i s a v a i l a b l e i n t he r e p o r t of t he In t e rcoun t ry Croup Heeting on the D e v e l o l e n t of Mental Health P r o g r a m e s , Amman, 1983.

Therapeutic c l a s s

5. A n t i e p i l e p t i c s

1 4 . Psychotherapeutic drugs

Comm. Health

phenobarb.

chlorpro- mazine

Health Centre

pheno- b a r b

chlor- prom. chlorpr . i n j . amitri- p t y l .

Gen Hosp

phenobarb. phenytoin diaecpam i n j .

chlorprom. chlorpr . i n j . a m i t r i p t y l diazepam f lupen i n j

TJHO-E?I/MENT/113-E page 26

b . 9 Research! needs and possibilities

At present, a limited amount of health research is in progress in the Iiezlon; most of this is not linked with service needs. Efforts to c0nduc.t operational research are greatly hampered by the lack of adequate tra i l l ing of mental health professionals and lack of a research infrastructure. Coordina- tion between universities and ministries of health is very poor in this regard.

In spite of this, a variety of studies have been undertaken and success- fully completed in the countries of the Region. Useful experience in this respect has been obtained by centres in Egypt, Islamic Republic of Iran, Pakistan and Sudan who have taken part in WHO-sponsored collaborative studies and it was felt that further opportunities for such research should be sought.

In considering the development of mental health programmes in the countries several research themes appeared to be of particular relevance at this juncture. These include:

1. Examination of types of mental, neurological and psychosocial problems encountered in general health care services. This would include an estimation of rhe frequency of such problems, their current management. prognosis and outcome. Methods such as one-day census studies are Cost- effective and easy to use.

2. Uevelopment of indicators of mental health programme development. Here indicators of change and impact of interventions may have particular priority for study.

3 . The need to include management of mental health and related problems in newer settings requires research which will lead to the definition of treatment and rehabilitation regimens, of criteria for the assessment of institutions and services (e.g. day care facilities for children) and of the specific roles to be played by different professional and lay persons Involved in the prevention of mental illness and care of the mentally ill.

4. Comparative research and multl-centric investigations, both of which can be of imense specific and practical value for the countries concerned, require the standardization of assessment instruments, terminology and methods.

A list of important topics of research for the EM Region is also available in the report of the Intercountry Group Meeting on Development of Mental Health Programmes, han,lY83, as well as in the report of the Intercountry Meeting on Mental Health Research, Karachi, 1981.

TJHO-EM/MENT/ 113-E page 27

7 . SPECIAL TOPICS

7.1 - The r o l e .. of h e a l t h s e rv i ce s i n t h e prevent ion and c o n t r o l of a lcohol - and drug-re la ted problems

I n most of the world, t he re i s a t r end towards increased frequency and s e v e r l t y Of a lcohol - and d r u g - r e l a ~ e d problems, as w e l l as a l coho l and drug dependence, Although d i f f e r e n t drugs a r e predominant i n p a r t i c u l a r c u l t u r e s , a genera l d i f f u s i o n of p a t t e r n s of a lcohol and drug use ac ros s n a t i o n a l bounda- rles IS now t ak ing place. I n addition t o t he s eve re h e a l t h problems a s soc i a t ed with a lcohol and drug dependence, t h e misuse of t he se subs tances a l s o l e a d s t o acc iden t s , t o a wide range of psychosocial problems ( inc lud ing those a f f e c t i n g family l i f e and employment) and t o economic d i f f i c u l t i e s .

Inc reas ing ly , consumers a r e misusing more than one drug a t a t lme, s o t h a t a l coho l , n a r c o t i c s , psychotropics and v o l a t i l e s o l v e n t s i n t e r a c t t o produce even h ighe r risks t o hea l th . There i s evidence of an increase i n the avail- a b i l i t y of a lcohol and drugs on both t h e l i c i t and t h e i l l i c i t market.

It i s likely, t h e r e f o r e , t h a t increasing demand w i l l be made upon t rea tment systems i n many coun t r i e s . A t t h e same time, however, t he need t o develop e f f e c t i v e approaches t o prevent ion becomes a l l t h e more u rgen t , s i n c e t h i s represents t h e best hope for long-term s o l u t i o n s .

Countr ies i n t h i s Region are unevenly a f f e c t e d by drug- and a lcohol - re la ted h e a l t h problems. Although i n some of t h e coun t r i e s drug problems have long been acknowledged, t h e r ecen t r ap id i n c r e a s e h a s placed a new emphasis on com- b a t t i n g them. Such i s t h e case i n Egypt, I s l amic Republic of I r an and Pak i s t an . In o t h e r coun t r i e s t h e concern f o r drug-re la ted problems is more r e c e n t . Sudan, for example, r epo r t ed s e r i o u s concern a r i s i n g because of drug misuse in urban a r eas . EChat-chewing, wi th t he r e l a t e d h e a l t h problems, a f f e c t s some of t h e coun t r i e s which have taken a d i f f e r e n t s t ance i n r e l a t i o n t o them. Somalia has prohibi~ed the use, import, production and distribution of khat, and Democratic Yemen has taken e n e r g e t i c measures t o c o n t r o l t he kha t problem. In D j ibou t i a r ecen t workshop sponsored by WHO provided a complex p i c t u r e of t he problem i n that country. Other c o u n t r i e s i n which kha t i s a l s o used have a more l e n i e n t a t t i t u d e . Alcohol problems have a l s o begun t o emerge i n some of t h e coun t r i e s . Here t h e r e l i g i o u s i n f luence of Islam provides a major suppor t t o hea l th s e r v i c e e f f o r t s . Trends i n t h e f u t u r e development of these problems are unc lear . A number of c o u n t r i e s are unaware of drug and a l coho l problems o r r e l u c t a n t t o recognize t h e i r magnitude i n pub l i c .

Mental h e a l t h programnes musr inc lude measures t o prevent or control t he problems r e l a t e d t o a l coho l and drug abuse. These measures inc lude :

1. Advucacy of public health intercat in ooc ie ta l decisions about the use of a l coho l and both l i c i t and i l l i c i t drugs6

WHO-EM/EIENT/~ 13-E

page 28

2 . Development of techniques which allow early identification of those at high risk and of effective techniques of prevention and treatment. These techniques must be tested in the sociocultural settings in which they will be used and whenever possible must be suitable for use at PHC level,.

3. Facilitation of technical cooperation between countries in their efforts to combat these problems. Such cooperation may be useful in the provision of training for trainers, in comparative research and in control measures for which success is more likely if several countries collaborate in their implementation.

Collaboration with other social sectors (e.g. the judiciary) is of particular importance in this progranune area. The health sector, in spite of increaa~ng emphasis on reducing demand for, rather than supply of drugs, in fact probably has a lesser role to play in the resolution of these problems than other social sectors. This is due to the complex aetiology of drug-related problems and the multiplicity of social and economic factors influencing their size and malignancy. Nevertheless, it is of essential importance that the Ministry of Health be assigned direct and full responsibility for programs concerned with health aspects of drugs and alcohol use.

WHO is the technical executive agency for UNFDAC-sponsored activities to combat drug dependence problems. More effort, however, will be necessary to harmonize Lhe efforts of UN agencies as well as those of non-governmental organizations active in this field.

7 . 2 Behavioural sciences

It is often argued that developing countries have so many urgent health problems of malnutrition, infections, poor sanitation, over-population, etc. for whlch they need urgent practical solutions: their resources are so limited that they cannot afford the "luxury" of getting involved in behavioural science training and research for their health services. This argument is fallacious. Ln fact, developing countries need the input of behavroural sciences even more than developed ones. As experience during the last few decades has already shown, the health problems of developing countries cannot be resolved only by reliance on Lhe biomedical s L ~ a L r g i r s a d teclnlologies used in devclopcd countries. The presence of different health problems,within the context of radically different cultural and environmental circumstances, demands the implementation of new approaches. The PHI: apprnach, based on active community participation for the prevention of disease and the promotion of health, has emerged as the basic strategy of WHO'S efforts in developing countries. The emphasis on PHC has given rise to a unique need for altering behavioural patterns and life-styles of both urban and rural populations in developing countries. This need has produced new and exciting possibilities and challenges for linking the behavioural and biomedical sciences in the world-wide movement toward "Health For All by the year 2000".

WHO-EM/MENT/ 113-E

page 29

A consultative group meeting on application of behavioural sciences in health services in d e v c l o p i n g countries war rnnvened in the WHO Eastern Mediterranean Regional Office, Alexandria, 2-5 September 1985. The report of this meeting was reviewed by the group. The group endorsed the conclusion of the meeting that. in view of the demonstrated importance of hurnan behaviour in the aetiology, control and p r e v e n t i o n of human disease and the promotion of human heal th,it is important c h a t appropriate behavioural sciences know- ledge and technology be immediately applied to the health services of develop- ing countries. WHO should continue to a s s i s t in promutirig col labori l t ion in the behavioural sciences between universities, research centres and ministries of health.

8. CONCLUSIONS

Thc i n t e r c o u n t r y mee t ing on mental health programmes in the countries of EMR brought together participants from 17 Member States. The situation in the countries was reviewed and several trends were identified:

8.1 The awareness of the size and nature of mental, neurological and PYYCIIU- social problems has increased in most countries; with it has also increased the readiness of decision-makers to develop or strengthen national mental health programmes.

8 . 2 There is a continuing increase in human and material resources which could be used for mental health programmes. Most countries i n the Region now have nationals trained in mental health disciplines. Some innovative models of training and of service provision have been put into opsration and technology for rn~ntal health programmes has h e m devcslopcd. 711 1-7 i y rac?rries mental health care is being decentralized and it has be2n shown that mental health components can be incorporated into PHC. In comparison with the 1983 situation reported in the intercountry meeting on development of mental health programmes in Amman, further encouraging improvements in mental health programmes have occurred.

8.3 Although there has been a ~rualrer of significant improvements i n mental health service provision for the mentally ill, mental health action has still remained unbalanced, in that there is still insufficient emphasis on the. prevention of mcntcil, neurological and pfiychosocial problems, on the promotion of mental health and on ensuring that mental health programmes contribute to the functioning of general health care and to overall development planning. The need to develop comprehensive national mental health programmes whish will deal with these matters has been unanimously underlined and seen as most urgenc

8.4 Several new problems have emerged in the countries of the Region. These include the resurgence of drug-related problems, the appearance of a l c o h o l - related problems, the increase of psychogeriatric problems and of mental health problems related to rapid social change and upheaval, and the increasing lack of clariry about the rules of members of mcntal health professions ( e . ~ . psvchia- trists, psychologists, social workers, etc.) ,

WO-EY/MENT/~~~-E page 30

Several specific recomnendations were made by the participants. These can be grouped as follows:

9 . RECOMMENDATIONS

9.1 Development of national programmes of mental health

1 . Governments are urged to develop national mental health programes w h i c l ~ can be incorporated into national health plans and strategies for iiF,'t/2000. Such programmes should have a broad scope, including not only the prevention and control of mental, neurological and psychosocial disorders, h!lt also the promotion of mental health and a specific effort to support general health care and overall socio-economic development through the provision of relevant skills and knowledge.

9.1.2 Comprehensive national mental health programmes require intersectoral cooperation and support of mental health and general health personnel. Every effort should be made to mobilize public and prof~ssional suppnrt for mental health programes: this may include generation and publication of data and use of media.

9.1.3 'f%e topic of mental health and the need for developing programmes shouId be discussed at a future session of the Regional Committee of .the EM'Region.

9.1.4 An intersectoral national coordination comittee 60r mental health should be established in each country.

9.1.5 A senior officer in the Ministry of Wealth should be designated as being responsible for the development and implementation of-a national mental health programme.

9.1.6 WHO should sponsor and provide technical cooperation for national work- shops aimed at developing national programmes of mental health.

9.1.7 WHO should sponsor an intercountry workshop to orient leading mental health professionals toward the PHC approach and the managerial process of national health development.

9.1.8 In order to facilitate the development of national programmes for mental health, WHO collaboration should be extended to the improvement of mental health service records, to the training of personnel in the generation of data for use in developing national plans and to strengthening of information transfer in the field of mental health.

9.1.9 The group recommended that WHO should actively collaborate with national institutions in the dcvelopment of technologies relevant to national health programmes, for example treatment schedules, rehabilitation programmes, preven- tive and promotive activities and relevant evaluative research.

WHO-EM/MENT/ 113-E page 31

9 . 2 ManDower deve lomen t

9 . 2 . 1 \RIO should provide f i n a n c i a l and t e c h n i c a l suppor t f o r strensthenin~ fnci 1 it ies wi th in t h e Renion f o r t r a i n i h g of mental h e a l t h workers and t eache r s of mental h e a l t h , and t he development of l e a rn ing m a t e r i a l f o r va r ious c a t e g o r i e s of h e a l t h personnel i n l o c a l languages.

9 . 2 . 2 The mental h e a l t h and behavioural s c i ences component of t he c u r r i c u l a i n medical schools and o t h e r h e a l t h personnel t r a i n i n g institutions shml'ld be reviewed i n o rde r t o r ende r i't more app rop r i a t e t o c u r r e n t country needs.

9 .2 .3 Recognizing t he c o n t r i b u t i o n which could be made by pro- f e s s i o n a l s helonging t o d i f f erenc healL.11 I ] i s c i \ ~ l ines in the dcvclopment of n a t i o n a l programmes f o r mental h e a l t h , i t was recommended t h a t TdNO should convene a c o n s u l t a t i o n involv ing r e p r e s e n t a t i v e s of such discipline6 (psychology, psychiarry, s o c i a l work, psychiatric nu r s ing , e t c . ) t o examine t h e c u r r e n t s i t u a t i o n and develop ways and means for product ive i n t e r d i s c i p l i n a r y c o l l a b o r a t i o n .

9 . 3 Drugs

9.3.1 Recognizing t h e importance of e s s e n t i a l d rugs f o r t h e proper implemen- t a t i o n of n a t i o n a l programmes of mental h e a l t h t h e group recommends t he i d e n c i f i c a t i u n uf a de f ined range of drugs for neuropsychiatric c a s e s which should be made a v a i l a b l e a t d i f f e r e n t l e v e l s of h e a l t h ca r e .

9.3.2 The group recommends that Member S t a t e s i n t h e Region which have so f a r no t become s i g n a t o r i e s t o t he U N Convention concerning p sychoac t i ve subs t ances should do so a s soon a s p o s s i b l e and p a r t i c i p a t e i n t he implementation of impor t - re la ted a c t i v i t i e s .

9 . 3 . 3 The group, having taken n o t e of t h e i n c r e a s i n g n a t i o n a l concern about drug dependence i n many c o u n t r i e s of the Region, recommends t h a t t he m i n i s t r i e s of h e a l t h should have a d l r e c t and f u l l r e s p o n s i b i l i ~ y fur h e a l t h aspccto o f

drug- re la ted programmes. These programmes should be an i n t e g r a l p a r t of t h e o v e r a l l n a t i o n a l programme f o r mental h e a l t h and we l l i n t e g r a t e d i n t o t h e hea lch sys tem of tile c o u n t r y . Every effort should bo made to p n s ~ ~ r e e f f e c t i v e i n t e r s e c t o r a l c o l l a b o r a t i o n i n combatting t h e problem of drug dependence.

WHO-EMIMENTI 11 3-E page 32

9.4 Research

9 . 4 . 1 . The group recommended that WHO provide necessary financial and technical support to the planning and implemenracion of reararc11 which is directly relevant to the planning and implementation of national programmes of mental health.

9.5 Other - 9.5.1. The group recognizes the important role of non-governmental organizations in mental health programmes and supporcs cheir active participation.

WHO-EM/KENT/ 1 1 3 4 page 33

ANNEX I

AGENDA

1. ' Inauguration of the Meeting

2. Election of officers

3 . Adoption of the Agenda and the Programme of Work

4 . Review of the progress of activities in the field of mental health in countries of the Region

5. Development of national programmes of mental health 5.1 General principles and guidelines 5.2 Formulation of a manta1 health rnmpnnent of national health

policies and plans 5.3 Development of a plan of action at national level

6. Supportive mechanisms for the development of mental health services at the primary health care (PHC) level 6.1 Training in mental health for health personnel working in PHC

6.1.1 Short training courses for general physicians 6.1.2 Short training courses for other health personnel 6 . 2 . 3 Mental health knowledge for health administrators

6.2 Provision of essential drugs for neuropsychiatric scrvices 6.3 Development of an adequate information system for mental health

services 6.3.1 Basic mental hea l th recnrds at PHC centres 6 . 3 . 2 Essential outpatient and inpatient records for psychiatric

centres 6 . 4 Development of an adequate referral system for support of mental

health services at PHC level 6 . 5 The emerging role of 'mental health professionals in the organization

of services at PHC level 6.5.1 Psychiatrists 6.5.2 Psychologists 6.5.3 Social workers 6.5.4 Nurses

7. The existing and future role of mental health services in the prevention and c o n t r o l of a l c n h n l and d r n g dependence

8. [Jays and means of promoting the application o f behavioural sciences in health services

9. Consideration and adoption of the Report of the Meeting

10. Concluding Session

AFGHANISTAN

RAHRA IN

CYPRUS

DEMOCRATIC YEMEN

EGYPT

ISLAMIC REPUBLIC OF IRAN

JORDAN

ANNEX I1

LlST OF PARTICIPANTS

Dr Burna A s i f l I n t e r n a t i o n a l Rela t ions Department Ministry of P u b l i c H~alth

Kabul - Dr A11 M. Matar P s y c h i a t r i c Hospi ta l Minis t ry o f Heal th P.U. Box 12 Man a m

Dr Georghios S. Malekides Dlreccor Mental Heal th Serv ices Min i s t ry of Heal th

D r Abdulla Hassan A l - ~ a t h i r i D i r ec to r P s y c h i a t r i c Serv ices Min i s t ry of Hea l th Aden - D r Ahmed Nayer Kotry D i r e c t o r MenLal Health D i v i s i o n

Min i s t ry of Heal th Cairo - D r Momtaz Mohamed Ahmed A s s i s t a n t Professor Mental Heal th ~ i v i s i o n Kasr E l Ain i Facul ty Cairo

D r Ahmed Mohit D i r ec to r Teheran Psychiatric I n s t i t u t e Tehrr at1

D r Ehsan Raafat Director

E l Karama Mental Health Hosp i t a l Amman

KUWA IT

LEBANON

LIBYAN A M B JAMAH IRZYA

PAKI STAN

SAUDI ARABIA

SOMALIA

SUDAN

Dr Esam Adel Al-Ansa?i Ministry of Health Kuwait

Dr Edward Azouri Mlnisrry of Health Beirut

Dr Ali Rouei Bengazi Psychiatric Hospital P.O.Box 37 Gwarshni - Benghazi

Dr M.H. Mubbashar Professor of Psychiatry Rawalplndi ~edical College Rawalnindi

Dr I . A . K . Tareen Professor of Psychiatry King Edward Medical College Lahore

Dr Osman Al-Taweel Director-General Mental Health Department Ministry of Health Ri y ad

Dr Mayeh Abu Omar niv i s i on of International Health Relations

Ministry of Health Mogadishu

Dr Hassab El Rasoul Suleiman Director-General Mental Health Ministry of Health Khartoum

Prof. Sheikh Idris Abdel Rahim Head Department of Psychiatry Faculty of Medicine Khartoum

SYRTAN ARAB REPUBLIC D r Kamal El Khatib Head of Mental Health Sec t ion Ministry of Health Damascus

Dr Yassein Mouftah Direc tor Preventive S e r v i c e s

Ministry of Health Damascus

Prof . Taouf ik Mohamed Skhiri Chef de Services de ~ s y c h i a t r i e Centre RSpi ta l -Univers i ta i re Monast i r

TUNISIA

YEMEN

Dr J . Hashmi

Dr N . S a r t o r i u s

D r N . N . Wig

D r Mohamed Abdullah Saad Sheibani Head of Department Teaching and Tra in ing of S t a f f Minis t ry of Health P.0.Box 299 Sana'a

OBSERVERS FROM HOST . COUNTRY -

D r Nabil Bayazid Psychologist Ibn E l Nails Hospital Damascus

D r Hanna Khouri Department of Psychological Medicine FaculLy uf I-ledicinc

Damascus

WHO SECRETARIAT

D ~ r e c t o r , Health Pro tec t ion WHO Eastern Mediterranean and Promo t ion Regional Off i c e

D i rec to r , Mental Health WHO Geneva Divis ion .. Regional Adviser on Mental WHO Eas tern Mediterranean H r a l t l ~ and Secretary of Rcgionol O f f zce

the Meeting

Dr H. Tawfik

Dr H.G. Egdell

Dr R.S. Murthy

Ms A. Hetata

Ms M. Orfali

WHO-EM/MENT/ 113 -E page 37

WHO Consultant

WQ Temporary Advibes

WHO Temporary Adviser

Conference Officer

Secretary

Psychiatrist, Mental Health Project - sana'a, Yemen

Consultant Psychiatrist Royal Liverpool Hospital Liverpool L78XP. England

Officer in charge ICMR Advanced Centre for Research on Lomnunlty Mental Health, Department of Psychiatry, NIMHANS, Bangalore, India

WHO Eastern Mediterranean Regional Office

WHO Eastern Mediterranean Regional Off ice

WHO-EM/MWT / 113 -E page 38

ANNEX 111

LIST OF BASIC DOCUWENTS

Provisional Agenda EM/INC.MTG. NAT. PMHII

Provisional Programme EM/INC.MTG.NAT.PMH/2

Llst of participants EM/ INC.M'l+G. NAT. P M H / ~

Country reviews b y participants EM/INC.MTG.NAT.PMH/~

Guidelines for developing national EM/INC.MTG.NAT.PMH/S,~ programmes of mental health (by H.G. Egdell)

Develup~nenL of a plan of action at national level (by N.N. Wig)

Mental health tasks for diff~rent levels of workers (by H.G. Egdell)

Provision of essential drugs for neuro- EM/LNC.MTG.NAT.PMH/~.~ psychiatric services (by H. ~ogerzeil)

Development of an adequate Information EM/XNC.MTG.NAT.PMH/~.~ system for mental health services (by H. Tawfik)

Development of adequate referral s y s t c m

for support of mental health services at the primary health care level {by R.S . Murthy)

The emerging roles of mental health professionals in the organization of services at the primary health care level (by R.S. Murthy)

The existing and future role of mental health services in the prevention and control of alcohol and drug dependence (by N. Sartorius)

UHO-EFf/MENT/ 113-E page 39

ANNEX I V

LIST OF RACKCROUND DOCUMENTS

1. Report on t h e i n t e r coun t ry group meeting on t h e development of mental h e a l t h programmes. Anman, 24-28 September 1983 (EM/MENT/~OS).

2 . Manual of mental h e a l t h f o r multipurpose workers, R.S. Murthy, 1985.

3. Manual of mental disorders t o r prlmary health care physicians, N.N. Wig, R. Parhee, 1984.

4 . Report of the consultative group meeting on a p p l i c a t i o n of behavioura l sc iences i n h e a l t h s e r v i c e s i n developing c o u n t r i e s , Alexandria , 2-5 September 1985 ( W H O I E M I M E N T I ~ ~ ~ ) .

5 . Mental hea l th c a r e i n t h e developing world, A b r i e f review of t h e

f i r s t phase of t h e WHO c o l l a b o r a t i v e s tudy on s t r a t e g i e s for extending mental h e a l t h c a r e , H.G. Egdell, Tropical Doctor 1983.