Mental Health and the Health System in Bangladesh: Situation Analysis of a Neglected Domain

Abstract

Mental Health constitutes a major public health challenge undermining the social and economic development throughout much of the developing world. It is estimated that mental disorders account for 13% of the global burden of disease (WHO 2008). However, in most developing countries mental health remains utterly neglected by the health system. In Bangladesh, for example, a meager 0.5% of the total health budget is allocated to mental health. On the other hand, as more than 65% of the total expenditure on health is out-of-pocket expenses, mental illness takes a heavy toll on the poor and the disadvantaged Based on a review of secondary data, the paper assesses the current situation of mental health in Bangladesh. The paper suggests that mental health care system in Bangladesh faces multifaceted challenges such as lack of public mental health facilities, scarcity of skilled workforce, inadequate financial resource allocation and social stigma. Bangladesh still does not have a comprehensive mental health policy to strengthen the entire health system. Clearly, the most crucial challenge is the absence of a dynamic and proactive stewardship able to design and enforce policies to further strengthen and enhance the overall mental health care. Such strong leadership could bring about meaningful and effective health sector reform, which will work more efficiently for the betterment of the health and social and emotional wellbeing of the people of Bangladesh, and would be built upon the values of equity and accountability.

Full text

American Journal of Psychiatry and Neuroscience
2015; 3(4): 57-62
Published online June 23, 2015 (http://www.sciencepublishinggroup.com/j/ajpn)
doi: 10.11648/j.ajpn.20150304.11
ISSN: 2330-4243 (Print); ISSN: 2330-426X (Online)
Mental Health and the Health System in Bangladesh:
Situation Analysis of a Neglected Domain
Anwar Islam
1, *
, Tuhin Biswas
2
1
School of Health Policy & Management, Faculty of Health, York University, Toronto, Canada
2
Department of Public Health, North south University, Dhaka, Bangladesh
Email address:
anwarhill@yahoo.com (A. Islam), aislam@yorku.ca (A. Islam), anwar.islam@icddrb.org (A. Islam)
To cite this article:
Anwar Islam, Tuhin Biswas. Mental Health and the Health System in Bangladesh: Situation Analysis of a Neglected Domain. American
Journal of Psychiatry and Neuroscience. Vol. 3, No. 4, 2015, pp. 57-62. doi: 10.11648/j.ajpn.20150304.11
Abstract:
Mental Health constitutes a major public health challenge undermining the social and economic development
throughout much of the developing world. It is estimated that mental disorders account for 13% of the global burden of disease
(WHO 2008). However, in most developing countries mental health remains utterly neglected by the health system. In
Bangladesh, for example, a meager 0.5% of the total health budget is allocated to mental health. On the other hand, as more
than 65% of the total expenditure on health is out-of-pocket expenses, mental illness takes a heavy toll on the poor and the
disadvantaged Based on a review of secondary data, the paper assesses the current situation of mental health in Bangladesh.
The paper suggests that mental health care system in Bangladesh faces multifaceted challenges such as lack of public mental
health facilities, scarcity of skilled workforce, inadequate financial resource allocation and social stigma. Bangladesh still does
not have a comprehensive mental health policy to strengthen the entire health system. Clearly, the most crucial challenge is the
absence of a dynamic and proactive stewardship able to design and enforce policies to further strengthen and enhance the
overall mental health care. Such strong leadership could bring about meaningful and effective health sector reform, which will
work more efficiently for the betterment of the health and social and emotional wellbeing of the people of Bangladesh, and
would be built upon the values of equity and accountability.
Keywords:
Mental Health, Health Care System, Situation Analysis
1. Introduction
According to the World Health Organization (WHO)
health is "a state of complete physical, mental and social
well-being and not merely the absence of disease"[1]. Mental
health, therefore, is an integral part of human health and
wellbeing. Mental disorders constitute a major public health
challenge and account for 13% of the global burden of
disease measured as disability adjusted life years [2]. Low
and middle income countries have higher burden of mental
disorders than economically developed countries [3, 4]. A
large number of people around the world are suffering from
psychiatric disorders. Mental illness constitutes four of the
ten most common causes of worldwide burden of disease,
yet it remains low on the agenda of policy makers,
particularly in developing countries like Bangladesh.
Unfortunately numerous organizations and NGOs that work
on chronic non-communicable diseases in Bangladesh also
largely ignore mental health. In Bangladesh the term chronic
diseases remain largely limited to diabetes, cancer,
cardiovascular diseases and hypertension. Needless to say,
these diseases are growing problems for the health system in
Bangladesh. As Bangladesh slowly but surely completes its
demographic and epidemiological transition; it is quit natural
to expect that chronic diseases like diabetes, cancer, cardio
vascular diseases and hypertension will emerge as major
killers replacing traditional communicable diseases [5].
However, despite being part of the chronic diseases, mental
illness of various types seldom gets attention when the issue
of demographic and epidemiological transition is discussed.
Contrary to overall general perception, mental illness
constitutes a serious threat to the national health. According
to WHO, more than 450 million people in the world are
suffering from neuro-psychiatric disorders and in
Bangladesh there are 15 million people suffering from
mental illnesses of various types [6]. In other words, almost
10 percent of the population is in need of mental health
services.
In Bangladesh, data related to mental health is scarce. So is

58 Anwar Islam and Tuhin Biswas: Mental Health and the Health System in Bangladesh: Situation Analysis of a Neglected Domain
the case with preparedness of the health system in providing
mental health care and services. This comprehensive review
was conducted to better understand the prevailing situation
and health system preparedness to address mental health
issues in Bangladesh.
2. Methodology
The paper is based on a review of published and
unpublished reports. Online search was conducted for
primary research articles on prevalence of mental disorders
covering both rural and urban areas of Bangladesh. Most of
the studies were focused on prevalence and co-morbid
conditions of mental illness. A few studies also focused on
utilization pattern of mental health services. The study also
reviewed NCD- related operational plans of the Ministry of
Health and Family Welfare as well as that of a few major
NOGs and mental health service providers in Bangladesh.
Two electronic databases (PubMed and BanglaJOL) were
extensively searched for relevant data and information with
especial focus on South- East Asia in general and on
Bangladesh in particular. However, the search was limited to
English language studies, articles, reports and other materials
only. In searching the data bases, the following key words
were used: “mental disorder”, “chronic disease”,
“depression”, “mood disorder”, “health services”, “mental
health services”, and “Bangladesh”. Titles and/ or abstracts of
selected articles were manually searched to identify materials
relevant for inclusion in the study. Reference lists from these
studies were also searched to identify additional relevant
studies /information. An extensive grey literature search was
also conducted by the authors.
Figure 1. Data extraction process
3. Results
3.1. Mental Health Situation in Bangladesh
Figure 2 shows the prevalence of mental health disorders
among the adult population in Bangladesh from 1974-2005
[7]. It is evident that although the prevalence of mental
illness in Bangladesh declined significantly between 1974
(31.4%) and 2005 (16.1%), it was still alarmingly high in
2005. The first national survey on mental health conducted
in 2003-2005 demonstrated that 16.1 % of the adult
population had some form of mental disorder and that the
prevalence of mental disorders was higher among women
(1 9 %) than men (12.9%) [8]. In other words, in Bangladesh
women are more vulnerable to mental illness than their male
counterparts.
There is widespread stigma against people with mental
illness in Bangladesh. There are many myths and
superstitions surrounding the cause and outcome of mental
illness. Mental disorders are primarily viewed as the result
of being possessed by evil spirits rather than as illnesses that
can be treated. Consequently, victims of mental illnesses are
most often neglected, subjected to delayed care-seeking and
abused [9].
Hossain et al in their systematic review study found that
prevalence of mental disorders among children in
Bangladesh ranged from 13.40% in 1998 to a high of 22.9%
in 2004 (Figure-3). A community-based survey conducted in
2009 found the prevalence of mental disorders among
children at 18.4% [10].
Source: Hossain et al 2014.
Figure 2. Prevalence of mental disorders among adults in both urban and
rural areas.

American Journal of Psychiatry and Neuroscience 2015; 3(4): 57-62 59
Source: Hossain et al 2014
Figure 3. Prevalence mental disorder among the children in Bangladesh.
3.2. Diagnostic Distribution of Behavioral Disorders in
Bangladesh
The primary behavioral and mental illness-related
diagnoses for women are depression and anxiety
(Chowdhury et al., 1981). A recent study reports that among
28,998 deaths in women aged 10-50 years, 11.4 percent were
attributable to suicide and depression (WHO, 2004). Priest et
al. (2008) reported high prevalence of antenatal depression
among rural women, who rarely seek treatment for their
depression [9]. Another study revealed that 14 percent of
women with depression admitted to thoughts of self-harm
during their current pregnancy [10]. This study found that 33
percent of women suffered from depression, which is
higher than the 12 percent prevalence reported in a
systematic review of studies undertaken in developed
countries [10]. Socio-cultural factors and physical violence
were also found to be associated with antenatal depression in
the study [11]. Researchers found that a woman who is
subjected to torture by her husband has the highest
probability of suffering from depression followed by an
unhelpful or unsupportive mother-in-law or spouse. In most
cases it is the preference for a male child and the failure to
produce one by the pregnant woman that make the husband
and/or the mother-in-law unhelpful and unsupportive [12] .
Behavior disorders are also a common health concerns in
Bangladesh. A study conducted by Rabbani and Hossain
(1999) finds that 13.4 percent of children had behavior
disorders (males 20.4 percent, females 9.9 percent) [13]. A
two-phased survey carried out on over 10,000 children aged
2 to 9 revealed that the prevalence rates of severe and mild
mental retardation were 0.6 percent and 1.4 percent
respectively [14]. This survey also found that mild mental
retardation was strongly and significantly associated with
low socioeconomic status [14]. Durkin et al. (1993, 2000)
used a structured measure for assessment of 162 flood
affected children who had been diagnosed with behavioral
disorders earlier; Durkin (2000) also found that an additional
10 percent had aggressive behavior and 34 percent had
enuresis [15]. There is an increased probability of developing
behavioral disorders for those who suffer from chronic
illnesses such as diabetes, heart disease and asthma that
equire timely treatment [16]. If people with chronic
illnesses ignore their behavioral health problems, they are
more likely to face negative health outcomes and
substantial amount of additional money later for their severe
illnesses [16]. Moreover, people with severe mental illness
are also less likely to access general health care. A lack of
proper diagnosis, inadequate and/or improper laboratory tests,
inadequate training of behavioral health specialists, length of
time spent without seeking care, inadequate space and
equipment combined with stigma, fear, and shame hinder
people with behavioral disorders from accessing mental
health care [16].
4. Discussion
4.1. Mental Health Services in Bangladesh
Table-1 presents an overall picture of mental health
services and their utilization in Bangladesh. It is clear that
within the broader health sector, mental health has fewer
facilities and beds. For example, beds in mental hospitals
account for only 8% of the total number of hospital beds. On
the other hand, there are no beds earmarked for the mentally
ill in forensic units across the country. Consequently fewer
mentally ill patients receive services in various institutional
facilities. Only 26% of service users in outpatients facilities
are mentally ill. Similarly, mentally ill constitute only 4.2%
of the patients served in Inpatient Units.
Table 1 Mental Health Facilities and their Utilization.
Variables %
Beds in mental health facilities and other residential facilities
Mental Health Hospitals 8%
Community Based Psychiatric
Inpatients Units 12%
Forensic Units 0%
Community Residential facilities 20%
Other Residential Facilities 60%
Mentally Ill Patients treated in health facilities
Outpatients Facilities 26.08%
Inpatients Units 4.18%
Residential Facilities 0.85%
Forensic Units 0.00
Percentages of female users treated in mental health facilities
Mental Hospitals 19%
Residential Facilities 81%
Inpatients Units 42%
Outpatients Facilities 44%
Percentage of children and adolescents treated in mental health facilities
among all users
Mental Hospitals 0%
Residential Facilities 73%
Inpatients Units 12%
Outpatients Facilities 7%
Source: WHO-2007
The country also has a small number of community care

60 Anwar Islam and Tuhin Biswas: Mental Health and the Health System in Bangladesh: Situation Analysis of a Neglected Domain
facilities for patients with mental disorders. National Institute
of Mental Health in Dhaka is the only national level tertiary
care mental health treatment and research facility in the
country [17]. Bangladesh has only one mental hospital that
was established in 1957 (WHO, 2007). In 1969 the first
outdoor clinic for the mentally ill was opened at the Dhaka
Medical College in the capital Dhaka. Later in 1981, the
National Institute of Mental Health (NIMH) was established
to provide training on mental health to primary care
physicians and health workers. In addition, a few NGOs are
also involved in mental health in the country, primarily
focusing on treatment and rehabilitation. In a country with
160 million people there are only a few outpatient mental
health facilities (n=50) and no community-based follow up
care or day treatment facilities. As noted earlier, there is only
one dedicated mental hospital in Bangladesh with 500 beds
where the average length of stay of a patient is 137 days. The
National Institute of Mental Health also runs a 150-bed
hospital in Dhaka. There are also 15 beds in the forensic
inpatient units, and 3,900 beds in residential facilities (e.g.
homes for the destitute, inpatient detoxification centers, and
homes for people with mental retardation). Quite a few
substance abuse treatment and rehabilitation facilities are
also there run by the private sector seldom mentioned in any
official register. Most mental health facilities, unfortunately,
are clustered in urban areas, especially in metropolitan cities.
The absence of a specific mental health authority makes it
difficult to systematically monitor and evaluate the mental
health services in the country.
4.2. Limited Mental Health Facilities
A total of 536 public hospitals with 37,387 beds provide
inpatient care services in Bangladesh for a population of 160
million [18]. In addition, there are 413 Upazila (sub-district)
Health Complexes with limited inpatient care services [19].
There is only one 500-bed mental hospital in the country.
There are 15 beds for mentally disordered people in forensic
inpatient units and 3, 900 beds in other residential facilities
such as homes for persons with mental retardation, inpatient
detoxification facilities, homes for the destitute, etc.
The density of psychiatric beds in or around Dhaka, the
largest city, is 5 times greater than that in the rest of the
country [20]. Antipsychotics, anxiolytics, anti-depressants,
mood stabilizers and antiepileptic drugs are included in the
list of essential medicines in the country [21]. However,
psychotropic drugs are not widely available [22]. Few
patients visiting government facilities are provided with
psychotropic medicines.
4.3. Financing of Mental Health Services
Mental health expenditure from the Ministry of Health and
Family Welfare is very insignificant and amounts to less than
0.5% of the total expenditure on health. Of all the
expenditure on mental health, 67% are devoted to mental
hospitals. In terms of affordability of mental health services
less than 0.11% of the population has free access to essential
psychotropic medicines. For those that pay out of pocket, the
cost of antipsychotic medication using the cheapest available
brand in local currency is Taka 5.00 (US$ 0.07) per day and
the cost of antidepressant medications using the cheapest
available brand in local currency is Taka 3.00 (US$ 0.04) per
day. Social insurance schemes, rare as they are, do not cover
any drugs for mental disorder.
4.4. Human Resources for Mental Health
Bangladesh has an acute shortage of human resources
trained in psychosocial health and/or mental health. There are
only 0.49 human resources trained and skilled in providing
mental health services per 100,000-population. Sadly there
are only 0.073 psychiatrists per 100,000-population in the
country most of them concentrated in major urban areas like
the capital city of Dhaka. The breakdown of other types of
human resources per 100,000-population is as follows:
medical doctors (not specialized in psychiatry but working in
mental health facilities) 0.18; nurses 0.19; psychologists 0.01;
social workers 0.002; occupational therapists 0.002; and
other mental health workers (including auxiliary staff, non-
medical primary health care workers, health assistants,
medical assistants and professional and para-professional
psychosocial counselors) 0.03. Majority of the psychiatrists
(54%) work in both government administered mental health
facilities and in private sector clinics; 46% work for
NGOs/for-profit mental health facilities or in private practice
[23]. It should be noted that due to such acute scarcity of
trained human resources, psychiatrists working in
government hospitals/facilities in Bangladesh are officially
allowed to simultaneously work in the private sector. Sixty-
two percent of psycho-social professionals (psychologists,
social workers, nurses and occupational therapists) work for
government administered mental health facilities, 26% work
for NGOs or in private practice, while 12% work for both the
public and the private sectors.
As for psychiatrists – most scarce mental health human
resource - 10 work in outpatient facilities, 33 in community-
based inpatient psychiatric units, and 4 in mental hospitals.
On the other hand, 70 medical doctors not specialized in
mental health, work in outpatient facilities; 140 in
community-based psychiatric inpatient units and 15 in mental
hospitals. As for nurses, 21 work in outpatient facilities, 220
in community-based psychiatric inpatient units and 140 in
mental hospitals. Four psychosocial professionals
(psychologists, social workers and occupational therapists)
work in outpatient facilities; 3 in community-based
psychiatric inpatient units and 3 in mental hospitals. Most of
the other mental health workers (20) work in community-
based inpatient psychiatric units, and 10 in mental hospitals.
It is unfortunate that none of these mental health workers
choose outpatient facilities as their place of work. It is
interesting to note that while there 0.04 psychiatrist per bed
in community-based inpatient psychiatric units, in mental
hospitals the psychiatrist-bed ratio is only 0.01. However,
nurses are almost evenly distributed between the community-
based inpatient psychiatric unites (0.27 per bed) and mental

American Journal of Psychiatry and Neuroscience 2015; 3(4): 57-62 61
hospitals (0.028 per bed). So is the case with other allied
mental health professionals (psychologists, social workers,
occupational therapists, etc). While in community- based
inpatient psychiatric units there are 0.02 such allied
professionals per bed, in mental hospitals there are 0.03 such
allied workers per bed.
On the other hand, the distribution of human resources
between urban and rural areas is grossly disproportionate.
Most of the human resources (as well as tertiary level
care facilities) are heavily concentrated in urban areas [18,
24, 25]. For example, the density of psychiatrists as well as
psychiatric nurses in or around the largest city, the capital
Dhaka, is 5 times greater than the density of psychiatrists
and psychiatric nurses in the rest of the country.
4.5. Mental Health Policy in Bangladesh
The country has an old mental health policy named the
Lunacy Act that was enacted and put in place in 1912 when
the country was still a British colony (1757-1947). This
policy reflects an outdated perception of mental illness and
health. According to this policy, the term “lunatic” means “an
idiot or a person with unsound mind”. Besides defining the
term, the policy also has a provision for asylum or prison for
people with behavioral disorders if ordered by the courts.
The Act also crafted a set of rules and norms to be followed
by all actors involved with mental health. However, as these
norms, rules and values were developed slightly more than
100 years ago, they and the Act embodying them need to be
amended. India, a neighboring country of Bangladesh, has
already amended the policy in 1987 by replacing the term
“lunacy” to “mental illness,” updating the relevant definitions,
establishing new rules for licensing psychiatric hospitals, and
developing procedures governing the practice of admitting
and discharging people with mental illnesses [26]. Clearly
Bangladesh is in critical need of a new Mental Health Act
that would reflect the contemporary values and norms
associated with mental illness. The people of Bangladesh in
need of mental health care and services deserve quick action
in replacing the outdated Lunacy Act of 1912.
In 2006 Bangladesh adopted a mental health policy,
strategy and plan as part of its effort in promoting
surveillance and prevention of Non-communicable Diseases
(NCDs) [27]. The policy recommended a community-based
approach in addressing all mental health issues including the
provision of basic mental health services as part of the
primary health care system (WHO and MOHFW, 2006).
Nevertheless, mental health care in Bangladesh is still largely
administered under the outdated Indian Lunacy Act of 1912.
To remedy this situation, a new Mental Health Act has been
drafted and is currently awaiting legislative approval.
4.6. Social Stigma and Mental Health
In Bangladesh the level of awareness of and medical care
sought for mental illness is very low. Besides there is
significant social stigma attached to mental illness that has
severe impact on the health seeking behavior of people
suffering from psychosocial or mental illness. Social stigma,
on the one hand, prevents them from seeking care and, on the
other, makes them silently suffer from social isolation and
discrimination. Consequently, morbidity from psychiatric
illnesses remains high and a seldom understood and/or
recognized public health problem in Bangladesh. About 60%
of ever married women of reproductive age in Bangladesh
reported having experienced sexual and/or physical violence
that remains largely ignored by the government and the
power elites. Moreover, very little is known about violence
against unmarried female adolescents [11]. There are many
different forms of gender-based violence including: domestic,
dowry-related acid attacks, rape, forced abortion, and
trafficking for prostitution. Victims of all such forms of
violence suffer from severe enduring psychological as well as
psychosomatic illnesses [28].
A growing national concern, drug and substance abuse by
women and children has increased over the years. The trend
of drug consumption is high among the youth and teenagers,
between the age of 15 and 30 years. In recent years, drug and
substance abuse is fast increasing among young/adolescent
females [29]. Needless to say, there are severe mental health
consequences due to drug and substances abuse but the
services available are very limited. There are few government,
private sector or NGO-run facilities for drug and substance
abuse victims. Moreover, these are primarily located in urban
areas leaving rural people devoid of such services.
5. Conclusion
Clearly there is an urgent need to address social stigma
associated with mental illness and further strengthen the
availability of and accessibility to mental health as well as
substance/drug abuse services across the country. At the same
time, Bangladesh also lacks appropriately trained adequate
number of human resources for mental health services.
Despite the great efforts of the Dhaka-based National
Institute of Mental Health, the overall health care system is
yet to recognize and respond to the needs of the mentally ill.
Contrary to popular belief, it must be fully recognized by
policy makers and planners alike that mental illness
constitutes a serious threat to national health. It is important
to note that the WHO defines mental health as a “state of
well- being in which people realize their potential, can cope
with normal life stresses, can work productively and can
contribute to their community”. Last, but not the least,
Bangladesh urgently needs a twenty-first century Mental
Health Act that can serve the interests of the mental ill most
efficiently and effectively upholding the principles of equity
and fundamental human rights for all.
Acknowledgments
The author would like to acknowledge the valued support
provided by York University, Toronto, Canada and Global
Health Institute, North south University, Dhaka, Bangladesh
in carrying out the study.

62 Anwar Islam and Tuhin Biswas: Mental Health and the Health System in Bangladesh: Situation Analysis of a Neglected Domain
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