The Country

Nepal is a landlocked however, geographically diverse country and broadly divided into three main areas, the flat land Terai, the centrally hilly regions, and the mountainous regions in the north of the country. Within the 147,156 square Kilometers of land with 31.1 million people currently living in the total 7 provinces of Nepal. The life expectancy is 69 years for male and 72 years for females(1). The population growth is 1.7%. The majority of the people living in Nepal fall under the ages of 15-64 (74.6%), followed by 0-14 (19.5%), and 65 and older (5.85%). 1.6 million of the population falls under the age category of 20-24 and 5.8 million of the population are from 0 to 19 years of age. Nineteen percent of the population fall between the ages of 0-19  Nepal (2).

It is important in the context of the WHO finding Depression and anxiety are among the leading causes of illness and disability(3) among adolescents, and suicide is among the leading causes of death in people aged 15–19 years (1.5 million of the population fall under this category). Half of all mental health disorders in adulthood start by age 14. WHO futher states that “The quality of the environment where children and adolescents grow up shapes their well-being and development. Early negative experiences in homes, schools, or digital spaces, such as exposure to violence, the mental illness of a parent or other caregiver, bullying and poverty, increase the risk of mental illness.(4)” Worldwide, 8% of children and 15% of adolescents experience a mental disorder and suicide rate is the third leading cause of death among 15-29 years old(4). The consequences of not addressing mental health and psychosocial development for children and adolescents extend to adulthood and limit opportunities for leading fulfilling lives.

Globally, one in seven 10-19-year-olds experiences a mental disorder, accounting for 13% of the global burden of disease in this age group Depression, anxiety and behavioral disorders are among the leading cause among adolescents. Suicide is the fourth leading cause of death among 15–29-year-olds. The consequences of failing to address mental health conditions of this group of population leads to extension of the mental health issues into adulthood which impairs both physical and mental wellbeing and is a leading cause of illness and disability among adolescents(5).

Suicide related deaths account for 9 per 100,000 population, which is worsening since 2018 according to WHO. This is WHO data(6); the actual data is much higher as many cases are unreported and unaccounted for. Globally one person dies every 40 seconds by committing suicide.

Mental illness as stated by Government of Nepal is estimated to account for 18% of all noncommunicable diseases(7).  As of 2021, only one in four mental health facilities offered mental health related services and most of these were concentrated in major cities, leaving rural population underserved. On top of it, until 2021, of those offering mental health services only 16% had a health worker trained in mental health. (8) To address this lack, the Government of Nepal launched the National Mental Health Strategy and Action Plan 2020. Nepal started implementing World Health Organization’s Special Initiative for Mental Health(9). This included WHO Nepal providing evidence-based guidelines, technical intervention packages, rights-based frameworks, implementation guidance and training to the Ministry of Health and Population (MoHP). As a result, mental health services were extended to 35 of the 77 districts in Nepal.

The present-day scenario

Nepal has a significant shortage of mental health professionals, with only psychiatrists and clinical psychologists with MPhil in Clinical Psychology being registered. Clinical psychology training is limited, and there is a low intake of candidates, resulting in inadequate numbers of trained professionals. Short training courses have been introduced mainly by NGOs, but their quality and accreditation are questionable, and these professionals are not formally employed by the government. The government plans to train nurses and assistant nurses in delivering basic psychosocial services, but challenges in supervision and mentoring impact service quality. There is an urgent need to expand training for psychosocial service providers, while also supporting the existing training program.

The Geographical Challenges

Nepal is a landlocked country with two gigantic nations within its two borders, with the population of 30.1 million. The vast majority of the population lives under the poverty line and the nation depends largely on agriculture and remittances from migrant workers. Besides, Nepal poses great risks of fragile geography, economy largely depending on remittance, diverse socio-ecology and ethnic composition of the population attributed by a wide gap in resource distribution. Unemployment among the adult population is triggering out-flux of large numbers of youth to abroad for employment that results in a negative impact in Gross Domestic Product (GDP).

The findings of the National Mental Health Survey 2020(10) by the Nepal Health Research Council (NHRC) reveal that among adult participants, 10% had experienced any mental disorder in their lifetime, with 4.3% currently affected. Suicidal behavior in current month was prevalent at 7.2%, encompassing thoughts, attempts, and future likelihood of suicidal thoughts. Around 40% of adults discussed their symptoms with someone, primarily family members such as spouses (20.5%) and other relatives (22.4%). Approximately 23% sought treatment, often from non-specialist doctors (8.8%), faith healers (6.7%), and psychiatrists (6.5%). The average cost of mental disorder treatment over the past year was NRs 16,053, with additional expenses for transport and related costs. Barriers included wanting to solve issues independently (23.5%) and believing problems would resolve on their own (23.5%), alongside stigma-related concerns, notably fear of family perceptions (2.5%).

The Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) pandemic has made the nation realized the crucial need of mental health and psychological services in spite of having mental health care package developed in 2017, but it has not put priority in providing psychosocial services.

Acute lack of human resources

Lack of human resources in mental health is indeed a significant challenge in service delivery in Nepal. The country faces a shortage of trained professionals, including psychiatrists, clinical psychologists, psychologists, counselors, psychiatric nurses, and other mental health cadres. This shortage severely limits the capacity to provide adequate and timely mental health care to the population.

As of now, Nepal has an estimated 241 psychiatrists, as listed in Psychiatrists’ Association of Nepal (PAN) website, which is a relatively low number considering the country’s population of over 30 million people. Moreover, the number of psychiatrists per capita is significantly lower than the recommended ratio by the World Health Organization (WHO), which suggests one psychiatrist for every 100,000 people. In contrast, Nepal’s psychiatrist-to-population ratio stands at approximately 1:150,000.

The availability of other mental health professionals is even far more limited. For example, there are around 32 clinical psychologists in Nepal, and the number of psychiatric nurses is estimated to be extremely low.

The pressing needs

In Nepal, the demand for mental health and psychosocial services is on the rise due to factors including natural disasters, post-conflict reintegration, poverty, marginalization, vulnerable living conditions, migration and family separation, gender-based violence, substance abuse, growing need for psychosocial support among children and adolescents, and the promotion of community resilience through initiatives that foster social cohesion and collective coping mechanisms. It is noteworthy that around 20 people kill themselves every day in Nepal.

Addressing this demand necessitates a comprehensive strategy involving the development of culturally sensitive and inclusive community-based psychosocial support programs, the training and empowerment of local volunteers and healthcare workers to provide essential psychosocial assistance, the integration of psychosocial support services into healthcare systems and disaster response plans, the promotion of mental health awareness and stigma reduction through public campaigns and education, and collaboration with local and international entities to bolster resources and capacity for psychosocial support. By acknowledging and attending to the need for psychosocial support, Nepal can make significant progress in enhancing emotional well-being, resilience, and social cohesion among its population.

What the law says

The constitution of Nepal has ensured the right to basic health services to every citizen from the state. It has made provisions for providing free essential health services and ensuring equal access to health services. The National Health Services Act 2075, Section 3, Sub-section 4 (c) has included mental health services in the list of basic health services. Similarly, the National Disability Rights Act 2074, Section 7, has made provisions for health, rehabilitation, social security, and entertainment for persons with disabilities. Sections 35 and 36 of the Act also guarantee additional services and facilities for persons with mental or psychosocial disabilities.

In the 15th Five-Year Plan of the Nepal government (2076-2081), the expansion of mental health services at all levels has been included. In line with the Multi-sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases (2014-2020), a specific program related to mental health activities has been implemented. The existing policy provisions and action plans have been reviewed while preparing this plan and translated into concrete policies and programs to promote mental health, prevention, treatment, and rehabilitation in the country. The National Health Policy 2076 also mentions specific policies and strategies related to mental health.

The SDG Goals

The United Nations mentions in its Preamble “As we embark on this collective journey, we pledge that no one will be left behind. The 17 Sustainable Development Goals and 169 targets which we are announcing today demonstrate the scale and ambition of this new universal Agenda. They seek to build on the Millennium Development Goals and complete what these did not achieve. They seek to realize the human rights of all and to achieve gender equality and the empowerment of all women and girls. They are integrated and indivisible and balance the three dimensions of sustainable development: the economic, social and environmental.(11)”

The 17 SDGs are listed below:

“No Poverty” as (SDG 1), “Zero hunger” as SDG 2, “Good Health and Well-being” as SDG 3, “Quality Education” as SDG 4,  “Gender Equality” as SDG 5, “Clean Water and Sanitation” as SDG 6, “Affordable and Clean Energy” as  SDG 7, “Decent Work and Economic Growth” SDG 8, “Industry, innovation and infrastructure” as SDG 9, “Reduced inequalities” as SDG 10,  “Sustainable Cities and Communities” as SDG 11, “Responsible Consumption and Production” as SDG 12, “Climate Action” as SDG 13, “Life Below Water” as SDG 14, “Life on land” as SDG 15, “Peace, justice, and strong institutions” SDG 16 , and “Partnerships for the Goals” as  (SDG 17).

Among these Sustainable Development Goal 3.4 articulates about mental health by stating “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being(12)”

SDG Target 3.4 | Noncommunicable diseases and mental health: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being(12).

In addition, in Section 26 of the Preamble, UN declares “To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind. We commit to accelerating the progress made to date in reducing newborn, child and maternal mortality by ending all such preventable deaths before 2030. We are committed to ensuring universal access to sexual and reproductive health-care services, including for family planning, information and education. We will equally accelerate the pace of progress made in fighting malaria, HIV/AIDS, tuberculosis, hepatitis, Ebola and other communicable diseases and epidemics, including by addressing growing anti-microbial resistance and the problem of unattended diseases affecting developing countries. We are committed to the prevention and treatment of non-communicable diseases, including behavioral, developmental and neurological disorders, which constitute a major challenge for sustainable development.(13)”

There is, however, no mention about mental health as a separate entity or any specifics about mental health. Although WHO recognizes that Mental Health issues as posing as a significant “single largest contributor to global disability” and there are plenty of literature suggesting mental health conditions are responsible for 13% disability-adjusted life years(14).

The preamble mentions “mental health” only 2 times and “human well-being” once (12).

The new Agenda 26 mentions “To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care(11).”

The Goal 9.1 mentions, however that also in the context of building infrastructure and sustainable industrialization as “Develop quality, reliable, sustainable and resilient infrastructure, including regional and transborder infrastructure, to support economic development and human well-being, with a focus on affordable and equitable access for all(15)”

However, both UN and the WHO along with other world wide organizations emphasize mental health and prioritized it to reduce premature mortality from Non-Communicable Diseases and promote mental health and well-being. The World Mental Health Day are observed each year on 10th of October with a theme to raise awareness, reduce stigma and prioritize mental health in everyday life of individuals. The prevention, treatment, and rehabilitation of substance abuse and the reduction of substance abuse-related harm are also among the goals.  Nepal has also signed in different international conventions and treaties such as Convention on the Rights of Persons with Disabilities, the Convention against Torture, Convention on the Rights of the Child, etc., emphasizing the need to promote mental health, prevention, treatment, and rehabilitation.

Government initiative in launching “National Mental Health Care Program 2022” has facilitated care service in mental health with an explicit focus on biological model and included accredited standard training package in mental health (doctor and health workers with mhGAP module 2) through task shifting approach, activate referral system and pathway, filling of prescription and psychotropic medicines. But psychosocial counseling service is not put as a priority, which is reflected in lack of government seats for this service(16).

The initiatives

To increase capable human resource in mental health, National Health Training Centre has developed 6 different training modules, including related training materials. Among the six modules, module 1 focuses on basic psychosocial counseling skill training for nurses; module 2a, 2b focuses on Mental Health Training (mhGAP) for health workers who identify and prescribe treatment to the patient; module 3 focuses on capacity development of health workers in child and adolescent mental health; module 4 focuses on mental health awareness training for female community volunteers and other community people; module 5 focuses on health care managers capacity in managing mental health services in district and local levels; and module 6 is six-month psychosocial counseling training for health workers and others professionals.

Gaps in attaining SDGs

Despite government and non-government initiatives in developing and producing mental health human resources there has been a gap between growing service needs and the supply side. Since long psychiatrists, clinical psychologists with MPhil in Clinical Psychology and psychiatric nurses are the only registered specialized mental health workforce. While academic programs in psychology and counseling psychology are available at the bachelor, post-graduate diploma, and master’s levels, there is a perceived deficiency in clinical skills and exposure among the graduates from these university courses, and there is no attempt for their accreditation to deliver clinical services.

The way forward

With the emerging needs for community level psychosocial intervention, e.g. in refugee camps, decade long armed conflict, 2015 Earthquake etc., various short training courses were introduced mainly by NGOs and private institutions. However, the training duration and course designs vary in terms of duration and content.  Such courses are practiced mainly by NGO run projects with a crucial question in the quality without accreditation by government authority, which is not yet defined.

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