Iona Casley is an ICS volunteer and Youth Reporter who has just returned from her placement in Nepal
During our three months living in Nepal, we encountered a distinct lack of awareness with regards to mental health.
We worked with schools, women’s groups, the ward office, youth groups, and health posts. And yet at no point was the elephant in the room of mental health openly discussed in conversation. For someone who has been lucky enough to work for Mind, one of the biggest mental health charities in the UK, during a period of positive change, I found this shocking.
To tackle this problem in our community of Jharuwarashi we took to the streets with placards, chants and around fifty school kids.
The rally was born out of observing the differences between what we’ve come to take for granted in the UK and what is lacking in Nepal. There is only one mental health hospital in the whole country, based in Kathmandu, and a mere 110 psychiatrists, compared to the UK’s 7,068.
Even adjusting for population differences, that’s a mere 3.5 per cent of the human resources we have available in the UK. The few mental health specialists that exist are concentrated in the big cities, with most working in the private sector and a significant proportion (25 per cent) working outside of Nepal itself. Government investment in mental health in Nepal has also been historically shocking, limited to just 0.7 per cent of the health budget (compared to 11 per cent in the UK) .
Statistics betraying the insufficiency of mental health services in Nepal go on and on. But the biggest problem is the lack of data. This sounds boring and bureaucratic but without an understanding of the prevalence of the issue and how it can be best addressed there can be no framework for change. There is no nationally representative epidemiological data on mental health, with only small-scale studies conducted usually by NGOs on targeted groups of people. One of these studies from 2013 indicated that 37.5 per cent of Nepal’s population has mental health problems, a number which sadly will only have increased since the major earthquake of 2015. Needs assessments after the earthquake revealed high rates of depression, anxiety, suicidal ideation and hazardous alcohol use. Additionally, Nepal is still recovering from its bloody civil war which raged between 1996 and 2006 and claimed more than 13,000 lives.
These awful events have forced the government to take action on mental health, alongside the international community and NGOs who have been working in this area since the mid-80s. A post-emergency response plan was implemented by a number of NGOs in Nepal from 2016-18 to strengthen the health system, and WHO worked with the government to deliver its mhGAP training on mental health for health professionals in the worst affected areas. A year ago Nepal’s Department of Health Services held the first International Conference on Mental Health, resulting in a nine-point plan to improve services. Most significantly, the Nepali government identified mental health as a priority area in its 2014-20 action plan for the prevention and control of non-communicable diseases.
However, due to political instability and an inadequate budget, implementation of this plan (and that discussed at the conference last year) has stalled and the situation on the ground is much the same as ever. For most people there is no support remotely close to where they live, and, even if there was, many would be put off going due to the attached stigma they could face.
We repeatedly heard people saying men shouldn’t cry, and it took only a few weeks of living in Nepali culture to see how gender- and caste-based discrimination could negatively impact wellbeing. In Nepal, attitudes towards health and illness are often grounded in religious and superstitious beliefs, especially when it comes to mental health: problems may be attributed to the person’s behaviour in a past or present life, leading to blame and stigma. The prospect of seeking help in this context is incredibly daunting, and unsurprisingly many avoid doing so.
Although stigma and discrimination were found to be one of the major barriers for seeking mental health care in the community, there is no mental health education carried out among the general population by the public health system. NGOs often lead on awareness-raising programmes, but due to limited resources must target specific populations. Our own rally was attended mostly by school children and members of the youth club in our community, despite repeated attempts to get other groups to join in (staff from our local health post were absent, although they had shown initial enthusiasm). Thanks to the president of the youth club, we managed to pick up thirty more kids from another school, whose principal was incredibly supportive and told us he believed all his students should be involved in solving the issues in their community. The march itself was full of energy, with many colourful banners and chants. The children enjoyed it so much they asked whether we could go on a whole extra hour-long loop of the area, when we had been walking for an hour already!
While our rally was fun and we did all we could to involve everyone across the whole community, these kind of events led by outside parties will not bring about systemic change on their own. It is crucial that a nation-wide programme is run from Nepal’s own health system if any large-scale behaviour shift is to happen. Certainly engaging in conversations at the community level is the way forward, but these must be coordinated across the whole country and directed or at least endorsed by the government, not international NGOs.
According to the World Health Organisation, four out of five people with severe mental illness in low- and middle-income countries receive no effective treatment. From what we saw in Nepal, this shocking statistic is believable. There were the odd indications of things changing – a poster in a hospital in Kathmandu or children being willing to engage in discussions – but there needs to be a concerted effort to support those who are often the most vulnerable in society. Rallies help, workshops help, but if long-term, nationwide change is going to happen, as it sorely needs to, training and awareness-raising programmes must be led by Nepal’s government, supported as necessary by international NGOs, not the other way around.
That certainly doesn’t mean us volunteers are out of a job – we need to campaign and support key stakeholders at all levels to ensure everyone experiencing mental health problems receive support and are treated with respect.