A rights-based digital solution for public mental healthcare in Pakistan
By Asma Humayun, National Technical Advisor for Mental Health, Ministry of Planning, Development & Special Initiatives, Government of Pakistan
This year Pakistan’s federal Ministry of Planning, Development and Special Initiatives launched a Mental Health and Psychosocial Support (MHPSS) initiative. The initiative, which is supported by UNICEF as part of the country’s emergency response to COVID-19, includes the establishment of a Mental Health Coordination Unit at the Ministry to pilot the program in Islamabad, but with the possibility of extending this work to Pakistan’s other four provinces as well.
Under this initiative, on October 10th, World Mental Health Day, Pakistan will also be launching an innovative digital model for multi-layered mental healthcare that is both rights-based and scalable. The main interface for service users will be a helpline and three iOS and Android Mobile Apps, backed by an integrated web portal and learning management system.
These undertakings are historic, given the context of mental healthcare in the country. Resources for mental health in Pakistan are not only scarce, but highly inequitable. Existing services are concentrated in tertiary hospitals, and the predominant model of practice is bio-medical which means these services are responsive to moderate to severe mental disorders only. Furthermore, existing services are largely unregulated, and were greatly compromised by the added strain of COVID-19 which resulted in mental healthcare resources being diverted towards strengthening the country’s COVID response.
The rights-based considerations of the new model are unique. The first challenge was to design a service that was democratic and easily accessible. Pakistan is the world’s fifth most populous country, with a population of 220 million, and a high rate of digital penetration (an estimated 180 million mobile service users). Under the new model, users can book an appointment to consult a mental health professional via the web portal or call or send a message to the helpline to request an appointment. To avoid waiting in a queue or having to bear the cost of the call, a team of mental health professionals will call them back. In addition, community outreach teams that include teachers and youth groups will be trained to provide basic psychosocial support including identifying and referring those who need more help. These teams will be offered online training courses in English and Urdu, following which they will be connected to the central web portal through a mobile application.
The second challenge was to address a complex web of emerging mental healthcare needs during the pandemic e.g., supporting vulnerable populations including frontline responders, those living with disabilities, and victims of violence and discrimination. To this end, the MHPSS plan is being implemented through partnerships with line ministries (Health, Education, Special education, Poverty Alleviation & Social Safety), social enterprises, NGOs and particularly those working with the vulnerable groups described above, as well as the media.
Another application has specifically been designed to support front line responders and others struggling with moderate to high stress conditions. This application follows a hybrid approach where users will be helped to assess and manage their own condition (based on scientific protocols) whilst still being able to connect with the team for assistance, whenever needed. Once users are aware of all possible treatment interventions, they will be encouraged to be a part of their own clinical decisions.
The identity of the users will be protected. Once they register, they will be allocated a case number. The team will not have access to a user’s personal details or contact information unless a user decides to share this.
The third challenge was to offer evidence-based services which could be monitored and regulated. For this, mental health professionals were selected through a clearly-defined criteria of qualification, experience and recommendations by both trainers and peers. The roles and responsibilities of mental health professionals have also been clearly outlined at each tier. This web-based integrated system has been used to build capacity (training, supervision) of a team of 40 mental health professionals across three levels. The training resources used are evidence-based and not only adopt principles of rights-based care, but have also been contextualized given local needs and presented in English and Urdu. Treatment protocols for psychosocial or pharmacological interventions are based on best practices. Following their initial training, all team members will be able to use a mobile application to refer to assessment and treatment protocols during clinical work and seek supervision, whenever needed. In addition, all consultations will be recorded (with the permission of users) for monitoring and supervision of the team. Users will also be invited to give feedback about the service. Formal referral channels are also being set up with existing services in tertiary care.
The program has been designed over a four-month period. Twice a week, an e-letter is shared with a directory of 800 mental health and policy stakeholders across the country. The transparency of this process aims to encourage accountability, share experiences for collective learning and feedback for improving developing services.
Finally, there is a crippling data gap around mental healthcare needs in Pakistan. These new integrated systems are being designed to save and consolidate all relevant data.
Unlike previous experiences, this initiative has the potential to develop into a sustainable and scalable service. The Ministry of Planning, Development and Special Initiatives is already exploring ways to allocate a separate budget soon after completing the pilot evaluation, and consider the feasibility of extending this work to the provinces.