Human resources for mental health - challenges and opportunities in developing countries.

Human resources for mental health are a challenge in all countries. In countries rich and poor, there is a big gap between the need for mental health services and the availability of those services. In an unusual way, the barriers to mental healthcare appear to be universal, which is not true of non-psychiatric healthcare. Nonetheless, the World Health Report 2001 and the World Health Organization's Atlas project have recorded extremely low levels of service in most developing countries (World Health Organization, 2001a,b). The recruitment of consultant psychiatrists from low- and middle-income countries, discussed in the October 2004 issue of International Psychiatry (Ndetei et al, 2004; Jenkins, 2004), raises a number of challenges for both developing and developed countries.

The World Health Report 2003 (World Health Organization, 2003) recognised the importance of human resources:

‘The most critical issue facing health care systems is the shortage of the people who make them work. Although this crisis is greatest in developing countries, particularly in sub-Saharan Africa, it affects all nations.… Furthermore, all countries are now part of the global marketplace for health professionals, and the effects of the demand–supply imbalance will only increase as trade in health services increases. Accordingly, new models for health workforce strengthening must be developed and evaluated.’

Human resources have been described as the heart of the health system in any country, the most important aspect of healthcare systems and a critical component of health policies (Hongoro & McPake, 2004).

The present article examines the effect of the migration of specialist personnel on a national mental health programme. It addresses three aspects of the issue, using India as an example:

The statement suggests that India has more than enough psychiatrists and that the loss of some will not have any significant effect. However, while adequacy of numbers may apply to doctors in general, it does not apply in the case of psychiatrists.

the reality of mental health services within the country

the role and responsibility of the Royal College of Psychiatrists in the recruitment of psychiatrists

the unique opportunities open to developing countries to plan their human resources for mental health.

First, however, it is of interest to note the emotive nature of the issue.

Professional reactions to international recruitment

In order to gain a better understanding of professional reactions to the overseas recruitment of mental health professionals, I wrote to a handful of colleagues, seeking their reactions to it. These, as expected, covered a wide spectrum. For example, one senior psychiatrist opined:

‘It is to an extent an unethical and exploitative practice. It amounts to the intellectual property of poor countries going cheap to rich countries as the individuals cannot be blamed for accepting the NHS UK jobs; a country like India, which is so acutely short of psychiatrists, cannot afford to lose its highly trained manpower, leaving its own people in desperation.’

At the other extreme was the opinion of another professional: ‘in this age of economic globalisation, goods move to those markets which offer better process; so will services’. Other responses included: ‘people should look for local solutions to local problems’; ‘in a free world movements are inevitable’; ‘what is required is to develop an international Convention on this issue to generate consensus, awareness and guidelines to regulate such movements and how the donor countries can be compensated’.

I submit that the College should have stepped in more actively and shared its understanding of the mental health situation in India, and called for clear guidelines for the recruitment of psychiatrists from India.

The reality of mental health human resources in India

In her contribution Jenkins (2004) noted that:

‘We [the Department of Health] have worked closely with the Indian Ministry of Health in the development of the campaign in India.… The Indian Minister of Health and Family Welfare responded to a parliamentary question in July 2003 by saying that the overall availability of doctors [emphasis added] in India is sufficient.… It is vital to stress that we would not recruit from India if the Indian government did not want us to.’

The statement suggests that India has more than enough psychiatrists and that the loss of some will not have any significant effect. However, while adequacy of numbers may apply to doctors in general, it does not apply in the case of psychiatrists. By the most generous estimate, India has less than half the number of psychiatrists of the UK per capita (its population is 20 times that of the UK). Further, the distribution of mental health professionals and psychiatric beds across India is very uneven: states like Kerala, Goa and Delhi have high numbers but, equally, some have low numbers, like Himachal Pradesh (with 4 psychiatrists for some 5 million population) and Chattishgarh (with 12 psychiatrists for 20 million people). The situation of Himachal Pradesh is significant as it is one of the states recognised as socially most progressive (it came second in this respect in a recent ranking of states reported in India Today, 16 August 2004). However, it is very poor in mental health services; indeed, the state was not able to recruit a full-time psychiatrist for its district mental health programme until 2003. Without doubt, most of India has few specialist human resources for mental healthcare.

During the 2004 annual conference of the Indian Psychiatric Society, in Hyderabad, one of the biggest exhibition stalls was run by the UK National Health Service, for the recruitment of psychiatrists.

The responsibility of the Royal College of Psychiatrists

During the 2004 annual conference of the Indian Psychiatric Society, in Hyderabad, one of the biggest exhibition stalls was run by the UK National Health Service, for the recruitment of psychiatrists. Is this method of recruitment ethical? What should be the role of the Royal College of Psychiatrists in this regard?

The Royal College is a professional body with members from a large number of countries, including India. Its official publication, the British Journal of Psychiatry, is an essential journal in all psychiatric centres in India. The deliberations of the Royal College are viewed with respect by psychiatrists in India. There have been attempts to form a South Asia branch of the College, and this indicates the respect in which the College is held in many countries in the region.

I submit that the College should have stepped in more actively and shared its understanding of the mental health situation in India, and called for clear guidelines for the recruitment of psychiatrists from India. The College as a professional body has good knowledge of both the position of psychiatrists and the development of psychiatry in India and could have envisaged the effect of recruitment on the country. I cannot but find fault with the College on this account.

The opportunities for developing countries to rethink their human mental health resources

The shortage of specialist personnel can be seen as an opportunity to think of organising mental healthcare in a very different way, using a variety of community resources (Srinivasa Murthy, 2000). There should be a shift from service provision by relatively few specialist professionals to a wide range of mental healthcare providers.

There are a number of mental healthcare activities that can be undertaken by patients themselves, family members, volunteers, general health personnel and others in the service sectors, like education workers, police and prison staff. Such people can be trained specifically for a limited range of tasks. It is this approach that can address the human resource needs within mental healthcare (Srinivasa Murthy & Wig, 1983). More specifically, four avenues are open to address the need:

To enhance training in psychiatry within undergraduate medical education. Currently, the length of training (a few hours of lectures and a few clinical sessions) does not reflect the amount of mental health work a general medical doctor has to provide, and the skills for meeting service needs are not provided as part of the training. In some developing countries, such as Pakistan, Sri Lanka and Oman, major changes have been made to undergraduate training in psychiatry. There is a need for other countries similarly to reform their training curricula. Most courses are largely academic and do not provide trainees with opportunities to acquire the knowledge and skills relevant to the practical work of mental healthcare. Practical training is required, in clinical settings. Suitable modifications to the curriculum would open up the possibility of increasing human resources for mental healthcare. This could be achieved by linking the training to the development of national mental health programmes and the emerging roles of voluntary organisations.

To develop short training programmes for non-specialists, such as medical officers, general psychologists and general social workers and nurses. The training could emphasise the clinical and practical aspects, to suit the specific situation of the country or region or a programme, for example school mental health or rehabilitation.

To use a wide variety of non-professionals. Mental health programmes have pioneered the use of volunteers in suicide prevention, patients functioning as therapists in drug dependence programmes like Alcoholics Anonymous, and family members becoming therapists to other family members. The key characteristic of this sort of ‘service’ is the limited role individuals take on in one specific situation, in which they call on their own personal experiences. The strength of these personnel is in their focused expertise and their acceptance by help seekers.

To involve staff in other sectors. As part of the ‘deprofessionalisation’ of mental health services, personnel working in different sectors (e.g. education or police) have frequently been used. Here, the health worker, preschool teacher, schoolteacher, police officer and so on add on a component of mental health to their traditional work activities.

As part of the ‘deprofessionalisation’ of mental health services … the health worker, preschool teacher, schoolteacher, police officer and so on add on a component of mental health to their traditional work activities.