The Progress of Mental Health in Afghanistan

Afghanistan is a country of approximately 35 million people, where 99.7% practice Islam in an environment highly susceptible to flooding, droughts, and earthquakes (Central Intelligence Agency, 2018). The country has suffered a prolonged state of war and political instability since 1973, including the rise of the Taliban in 1994 (Central Intelligence Agency, 2018). According to the WHO, Afghanistan has one of the lowest life expectancy rates in the world, the second highest maternal mortality rate in the world, less than 40% of the country’s children receive life-saving vaccinations, and less than 23% and 12% have access to safe water and adequate sanitation, respectively (2002). WHO also estimates between “30% - 50% of a population undergoing violent conflict develop some level of mental distress,” not accounting for the decades of unattended mental health problems prior to, or despite, conflict (2002). The myriad of unmet health needs amongst the Afghan people is further challenged by the environment. While meeting the health needs of the most rural within a population is trying, it is made increasingly more difficult in Afghanistan due to the “remaining deadly land mines and unexploded ordnance,” daily adding “victims both through physical injury and mental stress, affecting every family in Afghanistan over time (World Health Organization, 2002).” It is apparent when looking at the country’s health statistics why mental health is not Afghanistan’s leading priority. The general socio-economic, cultural, and environmental conditions as described above lead the World Health Organization (WHO) to identify Afghanistan “among the very poorest in the world (2002).

Mental Health Professionals

A 2006 country profile stated that Afghanistan had only two trained psychiatrists and 60 physicians working in mental healthcare with training varying “from almost nothing to some in-service training or short courses in institutes abroad (Ventevogel, Nassery, Azimi, & Faiz, 2006).” As of 2014, the total mental health workers per 100,000 population totaled at 4%, with psychiatrists at 1% per 100,000 persons and psychologists at 4% per 100,000 persons (World Health Organization, & United Nations Population Prospects, 2014). Last year, the Afghan Ministry of Public Health (MOPH) “trained over 700 professional psychological counselors and 101 specialized mental health doctors,” of which “300 are currently working in government-run health centres while the others are working for different health NGOs (World Health Organization, 2017, April 9).” There is insufficient data regarding the current number of practicing psychiatrists in the country, as well as to whether or not the 60 doctors working in mental healthcare were among the 800 the MOPH trained.

Mental Health Professional Training

Comparably to the sparse number of trained mental health professionals in Afghanistan, so are the specifics around the training they receive. As mentioned above, the MOPH does not go into any detail regarding the type, duration, and gained skills of the 800 mental health professionals who received training (World Health Organization, 2017, April 9). The most comprehensive mental health training was reported in 2009, when the Afghan Mental Health Department (MHD) developed a comprehensive mental health strategy, providing mental health “treatment and basic counseling training manuals for doctors; basic counseling manuals for nurses, midwives, community health supervisors and the community health workers (Sayed, 2011).” In addition, a “one-year curriculum [was] developed for training professional psychosocial counselors (Sayed, 2011).” What this one-year curriculum contained, or the treatment and basic counseling training manuals communicated, is not detailed by the Afghan MHD (Sayed, 2011). Alongside the socio-economic and environmental challenges Afghanistan faces, the cultural stigma still pervasive around mental health presents an even bigger challenge in not only engaging citizens in mental health discussions but pursuing mental health as a profession (World Health Organization, 2017, April 9).

Inpatient And Outpatient Services

There is no reported data on the number of mental health outpatient facilities, and it is reported that there are zero outpatient treatment facilities (World Health Organization, & United Nations Population Prospects, 2014). There is also no data regarding the number of citizens receiving outpatient care per a 100,000 population (World Health Organization, & United Nations Population Prospects, 2014). There are only six inpatient service facilities, five being psychiatric units in general hospitals, one being a mental hospital, and no residential care facilities reported (World Health Organization, & United Nations Population Prospects, 2014). Within mental hospitals, there is nonreported data regarding the number of inpatients, but as of 2014, 36% of admissions amongst inpatients were involuntary, and 1% of inpatients discharged followed up within one month (World Health Organization, & United Nations Population Prospects, 2014).

The lack of data regarding inpatient and outpatient services may have a strong correlation between underreporting due to the cultural stigma around mental health and voluntarily seeking mental health treatment. As of 2018, only 320 hospital beds in the public and private sector are available for people suffering from mental health problems (“Mental and disability,” n.d.).” Afghanistan also has only one high-security psychiatric facility, where “many of the patients are often chained and sedated (Raphelson, 2018).” Approximately 300 patients are housed in this facility, and “due to the lack of adequate outpatient mental health services,” patients with manageable mental health problems who could succeed outside of the hospital, are “basically stuck in there forever (Raphelson, 2018).” The majority of patients housed within the psychiatric institution are “from all different walks of life, but most [of them] are in the hospital as a direct result of war,” providing further insight into the complexities of providing adequate mental health services to an entire country effected by war (Raphelson, 2018).

Payment Mechanisms And Medication

Afghanistan’s MOPH identified and developed a program for seven priority areas of healthcare service that should be available to all Afghans, regardless of region, known as the Basic Package of Health Services (BPHS) (Ministry of Public Health, 2005). Mental health is listed as one of the seven priority areas, and these services ensure “everyone who needs care must receive care, regardless of ability to pay [and] quality of care must be the same for paying and nonpaying patients” (Ministry of Public Health, 2005). Alongside the BPHS, the Essential Package of Hospital Services (EPHS) operates on a hospital provider level, ensuring trained staff and adequate equipment and medications. The health system, however, is “evolving towards a split purchaser/provider model, with the Ministry of Health assuming a stewardship role and running secondary and tertiary hospitals (World Health Organization, 2012).” More than 80% of primary healthcare services are delegated to nongovernmental organizations (NGOs) and under the “Performance-based Partnership Agreements (PPAs), the government contracts NGOs to provide a BPHS within geographically defined areas and under a national policy framework (World Health Organization, 2012).”

While the cost per person to utilize the BPHS by service (e.g. inpatient or outpatient) and need (e.g. mental health or maternal and newborn health) are not detailed, “patients mostly pay for medicine and diagnostic examinations that are not available in [the] majority of hospitals (Zeng et al., 2017).” According to a 2017 WHO report, essential medicine comes from private pharmacies and NGOs in accordance with the BPHS and EPHS. Most medicine is “imported from neighboring countries, sometimes illegally smuggled through uncontrolled, long and open borders (2017). While the idea of everyone receiving healthcare, regardless of a citizen’s location in the country, financial status, or need is the zenith of healthcare as a universal right, the actual implementation encounters barriers with understaffing, insufficient training, and inadequate funding.

Legislation And Policy

Afghanistan implemented mental health legislation in 1987, which includes “downsizing large mental hospitals, developing a mental health component in primary healthcare, human resources, equity of access to mental health services across different groups, advocacy and promotion, financing, quality improvement and monitoring systems (WHO-AIMS, 2006).” While available, this legislation is only partially implemented (“Mental and disability,” n.d.). The law received a score of 4 out of 5 regarding its alignment with human rights covenants, with a score of 5 being fully aligned (“Mental and disability,” n.d.). A regular, allocated budget does not exist for mental health, with 0.1 million USD used out of a 289.4 million USD budget directed for mental health (WHO-AIMS, 2006). In 2010, a stand-alone policy for mental health in Afghanistan was developed, and while similarly to the legislation, it is available but only partially implemented (“Mental and disability,” n.d.). Regarding its alignment with human rights covenants, the policy received a score of 3 out of 5 (“Mental and disability,” n.d.).

The foundation of BPHS, and the operationalization of EPHS on a provider level, have the impact to provide far-reaching mental health services to the people of Afghanistan. The policy and law already in place in Afghanistan also provide a solid foundation around the country recognition and concern for combatting morbidity and mortality from lack of, or inadequate mental healthcare. Barriers, however, such as allocated funding, cultural stigma around seeking mental healthcare, and the insufficient number of trained mental health providers, prevent citizens of Afghanistan from receiving vital services in order to heal from decades of mental health trauma.

Other Relevant Information

When searching the literature for “Afghanistan” and “mental health,”, the majority of searches produce results that are incredibly focused on the West. Combat veterans, the impact of PTSD amongst Americans after serving, and the exposure of war are common themes resulting from the literature.