Community Mental Health Services in Egypt

Abstract

As far back as the 14th Century, Egypt had already known mental health care in a community-based sense in Kalaoon hospital in Cairo, 600 years before similar institutions were founded across the globe.

By the year 2001, an Egyptian-Finnish bilateral comprehensive reform program was incorporated. A few years later, in 2007, the Minster of Health and Population initiated the commencement of a proper appraisal of the mental health services in Egypt, aiming at achieving better integration and coordination in the mental health sector, as well as supervision and training on a national, governmental and primary care level.

By the year 2009, The Mental Health Act of 2009 (Law 71) brought basic conceptual changes to the care of people with a mental illness in Egyptian institutions, replacing the outdated 1944 law that had been used in Egypt for decades. However, despite all of the important steps Egypt is taking to move forward for more integrated mental health services, more effort and resources are still needed to fight against stigma and to develop a comprehensive multi-disciplinary approach which is approachable and effective to all those who need it.

Full Text

Background

In Egypt, the concept and management of mental health in are presented from the Pharaonic era. Papyri, from the Pharaonic period show that they described mental disorders though theories of causation which were mystical in nature yet they were treated on a somatic basis [1]. In the 14th century, 600 years before similar institutions were founded in Europe, the first psychiatric unit was established, in Kalaoon Hospital in Cairo [2, 3].  It had sections for surgery, ophthalmology, and medical and mental illnesses. Astonishingly, the care of mentally ill patients appears to have been community based, probably for the first time in history [4]. However, the building of asylums away from resi­dential areas, to separate those with mental illnesses from their communities, began only in the late 19th century [5]. At the beginning of the British protectorate in Egypt,  the modern practice of asylum care took place to the extent that the Department of Mental Health at the Medical School of Cairo University was closed in 1880 and psychiatrists were directed towards the newly built asylums, where training for their profession was more vocational rather than academic [6]. In 1944, mental health legalization was introduced in Egypt, after agreement of the Egyptian parliament, in advance of most Arab and African Countries [7]. The law formed the basis of hospital practice of psychiatry for about 30 years. Not so astonishingly, by the 1980s, psychiatric hospitals were detaining numerous patients who did not suffer from psychotic disorders but rather had addictions or behavioural disorders (largely because of loop­ holes in the legislation); in fact, the involuntary detention of patients on moral grounds became a common practice [8].

 

 

Egypt is the most populous nation in the Arab world; its population is equivalent to 1.25% of the total world population. The nation is administratively divided into 26 governorates (regions) and Luxor City, and 203 districts. The four Urban Governorates (Cairo, Alexandria, Port Said, and Suez) have no rural population [9]. With its rapid increase of population, and economic, political, and military challenges in its modern history, economic growth has been affected, hence the medical and mental services have suffered by default.

Until the year 2000, there was an alarming treatment gap in mental health services, evident in a huge discrepancy between the number of people who needed therapy and those who actually received it. The total number of hospital beds for a population of over 75 million was 6156 (including the 680 forensic psychiatric patients at Khanka, 95 forensic beds at Abbassia, and 13 forensic beds at Ma'amoura). This was an average of less than 1 bed per 12,000 population across the country as a whole, compared with a WHO recommendation of 5-8 beds per 10,000 population [10]. Mental hospitals were mostly based in Cairo and Alexandria, with not enough attention to integration into primary care, and hence inadequate prevention, early detection, prompt management. With this concentration of mental health services and staff in hospitals in the largest cities 3 cities, there was hugely insufficient decentralisation across the country to all governorates, districts and communities [11]. Moreover, in real practice, when the national hospitals are excluded from the calculation, since it is not good practice to use them to admit people a long way away from their communities, in most governorates there are only 20 beds per 3 M, i.e., 1 bed per 150,000 population. This, bearing in mind that the prevalence of probable psychosis was at least 0.2%  [12].

An appraisal of the situation took place in 2001 after studying all the necessary data and conducting site visits and workshops, resulting in a six-year reform programme (Egymen) 2002-2007. This was initiated by Egyptian- Finnish bilateral aid, and then continued by the Ministry of Health and Population (MOHP) from 2007- present, with sustained technical support from the WHO Collaborating Centre (WHOCC), Institute of Psychiatry, the WHO Eastern Mediterranean Regional Office (EMRO) and WHO Geneva. The project was able to put into place a reform programme which has been sustained beyond the end of the funding with a lot of focus on appropriate treatment at the primary care level, strengthening the referral system, inter-ministerial and intersectoral liaison, rehabilitation, and media work to mobilize community engagement [11].

In May 2009, The Mental Health Act of 2009 (Law 71, pub­lished in the Official Gazette, issue 20, 14 May 2009) brought basic conceptual changes to the care of people with a mental illness in Egyptian institutions. This, like its predecessor, focused on the rights of those with a mental illness, independ­ent second opinions from psychiatrists, and patients’ right to consent to treatment. The real change in the environment of mental hospitals followed the policy of opening the gates to visitors, the press, and international professional organisations, such as the Royal College of Psychiatrists, the Arab Board of Psychiatry, the Institute of Psychiatry in London, and the World Federation for Mental Health, which all offered to support the work. Training workshops were con­ducted throughout Egypt.  In 2011, The Code of Practice of the Mental Health Act was redrafted (Ministerial Decree, Number 210) The new Code allowed the compulsory use of psychotropic medication to facilitate bringing people to hospital from their private homes without prior permission from the district attorney. Involuntary electroconvulsive therapy (ECT) without second opinion for up to three initial sessions also became legitimate. In addition, the role of patients’ rights committees was diminished [6].

The Organization of Mental Health Care

Mental health services in Egypt are provided through more than one system. First, the main provider is the General Secretariat of Mental Health (GSMHT), which is a part of the Ministry of Health and Population, managing 18 hospitals and centres in 14 governorates. Second, there are mental health departments in the general hospitals. The General Administrative section of the Ministry of Health and Population (MOHP) supervises private mental hospitals, non -governmental organizations (NGOs) and outpatient clinics all over the country, In addition to these, there are psychiatric departments in the medical schools of public universities [13], which are under the supervision of the Ministry of High Education, and also some psychiatric departments in military hospitals, under the supervision of The Ministry of Interior and Ministry of Defence [14]. Unfortunately, there was a lack of systematic linkages between the Ministry of Health and other departments within the MOHP (recently split into the Ministry of Health and the Ministry of Population), and other key ministries and key agencies, until the mid the 2000s [11]. According to the latest report, The GSMHAT now has 18 hospitals and centres providing mental health and addiction treatment services in 13 governorates (out of 27) with about 5237 beds  and 22 outpatients clinics [15].

Mental Health Services in Primary Care

Egypt has a relatively well-developed primary care system made up of two tiers, the first tier of which is the family health unit (FHU), the second tier, the family health centre (FHC). Each family health unit comprises doctors, nurses, social workers and health educators, and each family health centre has a similar core team of doctors, nurses, social workers and health educators. In addition to this core team, there are some specialists based in family health centres (e.g., paediatricians). The current role of the family health centre health team is largely to take referrals from the family health units, to see direct consultations, and to make referrals to the district level. Ideally, they would also take responsibility of overseeing the catchment area population and the FHUs within the catchment area, but this is not yet a specified part of their role. As regards to the integration of mental health services within the primary care services, this is run under the General Secretariat of Mental Health and Addiction Treatment (GSMHAT) which is a governmental body dedicated to the provision of mental health services and drug dependence treatment and rehabilitation. Its scope includes inpatient psychiatric hospitals, outpatient mental health care centres and primary health care services. GSMHAT supervises the 18 governmental mental health hospitals in Egypt. In addition, GSMHAT works as the main educational body in the area of mental health and addiction treatment. It does not only provide training to its own employees but extends it to all other service providers.

The total number of primary care units in Egypt (2017) was 5391, distributed across all cities according to population density in each city. Human resources per unit consist of a family physician, an internal medicine specialist, a surgery specialist, and 6 nurses and social workers. The actual number of physicians assigned in primary care units was 9022 whereas the target number which should have been assigned was 16000 physicians [15].

 

 

Day Centres

There has been a development of addiction day care centres in 4 GSMHATs (El Matar hospital-Abbassia hospital, El-Maamoura hospital and El Khanka hospital) To join this program, the client is required to complete the rehabilitation phase inside the hospital or achieve physical and psychological stability outside the hospital. The program includes psychiatric education, improving life skills for high-risk situations, motivation, CBT, family therapy, family consultation, and relapse prevention techniques) [15].

Specialized Services

Addiction:

15 out of 18 GSMHAT hospitals provide a service for addiction treatment (outpatient, inpatient, and day care units) with a total number of 563 beds. The majority of inpatient services for addiction treatment are provided by Abbassia Hospital, which is the large centralized mental health hospital [15].

Forensic Psychiatry:

Forensic psychiatry is mainly implemented in the Al Khanka and Al Abbassia hospitals, consisting of ten wards. The operating power of units by 2016 was 594- 613 beds, with occupancy rates range from 90% to 100% [15].

Child Psychiatry:

Forty percent of the Egyptian population are under the age of 18 years [9] and 15–20% of them need mental health services; unfortunately, only 5% of these individuals receive mental health services. Child and adolescent mental health services are provided by the public health sector (40%) and the public sector (60%), which comprise paediatricians (50%), general psychiatrists (20%), non-professionals (20%), child and adolescent psychiatrists (7%) and primary care physicians (3%). Meanwhile, educational services are provided by national governmental schools (70%), private sector schools (20%), and public sector schools (5%) [16].

According to the Pathway to Child and Adolescent Mental Health Services among Patients in Urban Settings in Egypt, in about 67% of mental health cases, the first contact is either with a paediatrician or a psychiatrist while 5% of cases seek traditional healers. Most patients are referred to the clinic by relatives (30%) followed by paediatricians (21%), schoolteachers (12%), and traditional healers (5%) [17].

Human Resources:

The total figure for human resources working as mental health providers in mental health facilities is 3,836: 2790 nurses, 117 psychologists and 224 social workers, according to the latest report by Noby [15]. The total number of psychiatrists registered in Egypt is around 1100 (Egyptian Psychiatrists’ Association, personal communication, 2018), 889 of them working within GSMHAT facilities.

Over the years outlined in this paper, the psychiatry component of the undergraduate curriculum has been improved, as well as the structure, content and delivery of the post graduate psychiatry training, and salaries have been doubled for trainees working in psychiatry at the MOH.

Discussion:

Over the past two decades, Egypt has been moving forward in a steady steps, aiming to improve mental health services. The Egyptian program together with the development of the Mental Health Act (Act No. 71 of 2009), has led to a major shift in the development of mental health services in Egypt. This change has manifested in the increase in investments in mental health services, and the organization of various awareness-raising campaigns for mental disorders, and national programs to combat the stigma of mental illness and to prevent discrimination against people suffering from mental health conditions. The 2009 mental health legislation and its code of practice provided not only a legislative process but also an opportunity to fight against stigma and increase public awareness, and to secure the rights of the patients [13].

This is also in parallel with considerable efforts in education and training, where, as previously mentioned, both undergraduate and post graduate education and training in psychiatry are much advanced, alongside a significant increase in trainee salaries. Trainees are now encouraged to start their postgraduate training early, and are given protected training and learning time. They are encouraged to take the Egyptian Fellowship Degree in Psychiatry. The Ministry of Health is establishing a recognized training programme in all districts; an appraisal system for trainees has been piloted, which is planned to be generalised this to all trainees, and it is also planning to establish a CPD system for all psychiatrists,  including trainees [11].

Nevertheless, there are still many gaps that prevent the complete fulfilment of the Egyptian government’s legal obligations with respect to mental healthcare. One of the main gaps can be seen in its structure itself, as the National Mental Health Counsel, which is the monitoring body, is chaired by the Minster of Health himself, who should in fact be monitored by the counsel. Mental hospitals are often based in urban areas. Their number is insufficient in areas such as Sinai, Matrouh, Hurgada, and New Waadi. Therefore, those who live in rural areas and seek to gain access to mental health care are burdened by travel and lodgings expenses, in addition to time and travel effort. Similarly, forensic psychiatric services are centralized (at Khanka, Abbassia, and Ma’amoura). The patients, especially those from rural areas, often go to traditional healers before or after seeking medical advice from the health system. Out-patient services are hospital-based so this issue also applies to these services [13].

Another main problem is that there is still a lack of systems for outreach to people with severe mental illness living at home, for home-based rehabilitation, and for intermediate services at governorate or district level. There are no community rehabilitation centres, day care centres or midway houses across the country apart from those linked to the national hospitals of Abbassia, Heliopolis and Khanka. When patients are discharged from hospital, there is a problem of them being unable to continue to access medicines. However, the mental health services in the Aswan governorate are conducting useful outreach, enabling hospital admissions to be greatly reduced, as is a pilot outreach project at Abbassia hospital [11]

 

Meanwhile, action needs to be taken to address the insufficient child and adolescent mental health services. Services need to be included in the country’s mental health agenda. The state has an obligation to provide specialized care for children and young people in light of the overwhelming data that suggests 50 percent or more of adult mental disorders begin before the age of 14 [18], and that children and adolescents with untreated mental disorders become an economic and social burden to the society [19]. Lefislative and policy reform also needs to be accompained by training, awarness raising campaigns, and reserch , for which adquate finicial resources need to be allocated as well. Yet, unfortunitly, ecnomic restrictions affect our ability to document and evaluate the excisting resources and outcomes, and prohibits overseas electives in child and adolescent mental health or becoming affilated with international recommindations and standards; hence , affecting the uniformity of our practice [20].

The majority of psychiatrists in governmental mental health hospitals were in the residency category, which is most probably related to their needs for training and many of their duties being provided at hospitals. Another very important problem is the lack of adequately trained mental health nurses and social workers. Nurses need to be oriented to psychosocial skills, rehabilitation, and issues of patient welfare, including risk assessment and humane management of violence. There is no occupational therapy training programme either, and other professionals lack an OT orientation. There are psychologists, but it is unclear how many are in the health sector, and what roles they are playing [11].

There are no systematic mechanisms for delivery of CPD for mental and neurological health for other relevant public sector workers, including teachers, police, and prison staff. Traditional and religious healers are common, and people regularly consult them either before or during consultation of orthodox services.

Conclusion:

A national appraisal of the current situation, including the deficiencies, needs to be implemented to gain a full understanding of the gaps in the system. The lack of human resources implemented in highly qualified psychiatrists, social workers, mental health nurses and occupational therapists need to be addressed. Adequate financial resources are needed for better documentation and appraisal of the current situation, and for improvement in training and application of guidelines to be in line with the international standards.

×

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Copyright (c) Okasha T., Shaker N.M., Elgabry D.M.

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