Mental disorders are common in both high-resourced and low-resourced settings. While 15% of the global disease burden is attributed to these disorders, 75% of people in many low-income countries do not have access to the treatment they need because it is chronically underfunded and ignored by most policymakers (World Health Organization [WHO] Regional Office for the Eastern Mediterranean [EMRO], 2017).&nbsp;
Mental health services in Egypt are mainly provided by hospitals with insufficient attention given to integrating mental health into primary care (Jenkins et al., 2010). This leads to poor intervention, failure of early detection as well as poor rehabilitation and social inclusion. The cornerstone in this problem is the lack of expertise on mental health issues among practitioners, especially family doctors, nurses and social workers (WHO-EMRO, n.d.).&nbsp;
The majority of the available resources are allocated to a few large centralized psychiatric hospitals. These hospitals suffer from inadequate availability of beds for acute cases, especially due to the fact that the majority of the provided beds are occupied by long-stay patients (Okasha, 1999).&nbsp;
All of the above-mentioned reasons lead to poor-quality mental health services, which violate basic human rights, and to negative therapeutic outcomes, preventing people with mental disorders from enjoying the highest standard of physical and mental health (WHO, 2001; Institute of Medicine, 2001). Good quality services build people&rsquo;s confidence in mental health treatment so that they are keener to seek the care that they need. The available resources for mental health services are often not utilized effectively and efficiently. Poor allocation in Egypt is the major reason for poor quality mental health care. This needs to be rectified through the reallocation of the available resources and additional allocation of resources, including investing in research and monitoring systems. Advocacy, training and other culturally sensitive mechanisms such as lobbying can further help to defend the rights of the people with mental disorders.&nbsp;
Conceptualizing quality
Quality may be viewed from many perspectives, all of which are important. The Institute of Medicine (2001) defines quality clinical care as care that is equitable, timely, safe, efficient, effective and patient-centered. In the eyes of the service user, quality means improvement of symptoms, having a &lsquo;normal&rsquo; life and being treated with dignity and with full respect for their rights to independent decision-making. Families may conceptualize quality in terms of the amount of support to help them cope with the consequences of having an ill relative, as well as being provided with the information to deal with this condition and support the relative&rsquo;s integration into the community. A service provider may define quality as ensuring that their patients receive the best treatment. From the perspective of the policymaker, quality of care can be seen as the key to improving the mental health of the population, whose significance to the policymaker lies in its contribution to general well-being and impact on society at large. Finally, in mental health research, quality is defined as the success rate of providing services where people need them and the ability of the practitioners to identify, manage, refer and prevent mental health problems. This article describes a three-pronged strategic approach for enhancing mental health services through policies designed to improve quality and equity therein.&nbsp;
Mental health legislation
Law 71/2009 on mental health includes the establishment of the National Mental Health Council (NMHC) and a regional subsidiary council in every governorate that has inpatient mental health care to monitor the country&rsquo;s enforcement of the Mental Health Act of 2009 (Official Gazette, 2009; Loza, 2010). However, the current structure, regulated by law (Article 6), weighs heavily towards officials from or affiliated with the government: most of the members are government employees, chosen on grounds of their positions. Moreover, the Minister of Health himself, who should, in fact, be monitored by the Council, chairs the NMHC, so a change in this structure should be considered. The NMHC is supposed to be an independent monitoring body overseeing mostly government institutions and so it will be difficult to hold these institutions accountable if the body overseeing them is dominated by the Ministry of Health (Elnemais Fawzy, 2017).&nbsp;
Furthermore, the government proposed amendments to Law 71/2009 on mental health &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;care to parliament on 7 November 2019, and the parliament gave its approval in April 2020. As the Egyptian Initiative for Personal Rights (EIPR) (2019) notes: &ldquo;Although the explanatory memorandum of the proposed amendments states that they provide &ldquo;additional guarantees for mental health patients&rsquo; rights by providing adequate protection to the patient against ill treatment and exploitation,&rdquo; in fact, the amendments erode such protection&rdquo;.&nbsp;
An example of this is the amendment to Article 28 of the law, which originally states that psychiatric patients admitted involuntarily may not be given Electro-Convulsive Therapy (ECT) before an independent assessment by a psychiatrist, registered with the Mental Health Council, is conducted to review the opinion of the treating physician, within 24 hours of the patient&rsquo;s admission. The WHO&rsquo;s Resource Book on Mental Health, Human Rights and Legislation states that emergency treatment should not include irreversible treatments such as psychosurgery or ECT. The amendment to Article 28 enables an exception to the independent assessment, and by extension, the abuse of ECT by allowing the patient to receive two sessions of involuntary ECT &ldquo;when necessary&rdquo;. However, the amendment establishes this exception without defining necessity, nor specifying the arbiter of this necessity, the cause for haste and who can administer the treatment (EIPR, 2019).
A further drawback to quality mental health provision is that the law now applies only to patients in mental health institutions. In the future, mental health treatment should be available in other institutions such as rehabilitation centers, residential centers, outpatient clinics and primary health care, thus necessitating the expansion of the law's remit. In addition, legislative and policy reform needs to be initiated to address the insufficient child and adolescent mental health services. Such services need to be included in the country's mental health agenda.
Alignment of funding
Funding should only be allocated if there is evidence to show the cost-effectiveness of an intervention. If the intervention is not effective, funding should be withdrawn and reallocated to the other preferred methods.&nbsp;
There is a lack of attention to mental health compared to the rest of medical specialties. Okasha et al. (2012) showed that the government estimated that it allocated less than 1% of the total health budget to mental health services. Most of these resources are spent on central hospitals at the tertiary care level to accommodate more people, rather than providing mental health services in the community or at a primary care level to reach a wider base of the population. The state still needs to assert its commitment to implement the current legislation (the amended 2009 Mental Health Act) by providing mental health care services within the network of primary health care and the services available in general hospitals (secondary care level) and mandating community-based services, rehabilitative programs, and social support programs, referring only the moderate to severe cases to the psychiatric hospitals.&nbsp;
That the delivery of mental health services at the primary care level improves cost-effectiveness has been demonstrated by Funk et al. (2008) and Wakida et al. (2018). Directing the current fund to the implementation of mental health care services within the network of primary health care will save the budget needed for funding academic research, which is still limited and depends on the interests of the different financing organizations. Such studies are needed in order to prioritize mental health for resource allocation. Funds also need to be redirected to fight existing stigma. &nbsp;
Integrating quality improvement into routine service delivery
Egypt urgently needs a national assessment of the deficiencies of its mental health system. This would provide reliable information on existing needs and the barriers to mental health care. The outputs of such an assessment can then be used in lobbying and mobilizing public opinion to rectify these conditions and to explain to the executive and legislature. In addition to that, the Ministry of Health should conduct a survey to measure the burden and the actual prevalence of mental disorders on a regular basis by including it among the "100 Million Healthy Lives" campaign for the treatment and early detection of non-communicable diseases (NCDs).&nbsp;
Admission to a psychiatric institution, whether voluntary or involuntary, has to be separated from consenting to treatment. Consenting to admission does not mean consent to treatment. Consent should be gained with the provision of accurate information and without manipulation, for example, practitioners should not tell the person that they will be given a &ldquo;sleep therapy&rdquo; when they are in fact given ECT (Elnemais Fawzy, 2017).&nbsp;
The management plan has to be individualized: each person has specific needs that need to be responded to, management plans cannot be identical or extremely similar for multiple patients even if they have been found to have similar conditions. Moreover, the management plan has to be a result of a shared decision-making process between the medical professional and the patient. In addition, the management plan has to exist in written form. This written form has to be accessible both to the patient and to the clinical staff involved in the patient&rsquo;s treatment.&nbsp;
The changes in both service delivery and the policy framework proposed above will help to enhance the quality of mental health services and preserve the dignity of the service user. Central to the facilitation of an environment in which service users can achieve the maximum degree of functional independence and quality of life is a change in the discourse on the strategy to one which values evidence-based interventions and integration of people living with mental disorders in the local community.
References:&nbsp;
<ul>
<li>Egyptian Initiative for Personal Rights. (2019). Amendments to the mental health patient&rsquo;s care law violate patients&rsquo; rights to health and safety. Retrieved from <a href="https://eipr.org/en/press/2019/12/amendments-mental-health-patient%E2%80%99s-care-law-violate-patients%E2%80%99-rights-health-and-safety">https://eipr.org/en/press/2019/12/amendments-mental-health-patient%E2%80%99s-care-law-violate-patients%E2%80%99-rights-health-and-safety</a>&nbsp;</li>
<li>Elnemais Fawzy, M. (2017). Mental health care in Egypt: Review of current state, policy, and needs.&nbsp;International Journal Of Mental Health,&nbsp; 46(4), 339-345. <a href="https://doi.org/10.1080/00207411.2017.1367447">https://doi.org/10.1080/00207411.2017.1367447</a>&nbsp;</li>
<li>Funk, M., Saraceno, B., Drew, N., &amp; Faydi, E. (2008). Integrating mental health into primary healthcare.&nbsp;Mental health in family medicine,&nbsp;5(1), 5&ndash;8.</li>
<li>Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.&nbsp;</li>
<li>Jenkins, R., Heshmat, A., Loza, N., Siekkonen, I., &amp; Sorour, E. (2010). Mental health policy and development in Egypt&mdash;integrating mental health into health sector reforms 2001&ndash;9. International Journal of Mental Health Systems, 4, 17. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<a href="https://ijmhs.biomedcentral.com/articles/10.1186/1752-4458-4-17">https://ijmhs.biomedcentral.com/articles/10.1186/1752-4458-4-17</a></li>
<li>Loza, N. (2010). Integrating Egyptian mental health services into primary care: The policy maker&rsquo;s perspective. International Psychiatry, 7, 5&ndash;7.&nbsp;</li>
<li>Official Gazette. (2009). Law for the Care of People with Mental Disorders (Law 71, 2009). Cairo: Government of Egypt.</li>
<li>Okasha, A. (1999). Mental health services in the Arab world. Eastern Mediterranean Health Journal, 5(2), 223&ndash;30. Erratum in: Eastern Mediterranean Health Journal, 5(5), 1059.</li>
<li>Okasha, A., Karam, E., &amp; Okasha, T. (2012). Mental health services in the Arab world. World Psychiatry, 11(1), 52&ndash;54. Retrieved from <a href="https://doi.org/10.1016/j.wpsyc.2012.01.008">https://doi.org/10.1016/j.wpsyc.2012.01.008</a></li>
<li>Wakida, E., Talib, Z., Akena, D., Okello, E., Kinengyere, A., Mindra, A., &amp; Obua, C. (2018). Barriers and facilitators to the integration of mental health services into primary health care: a systematic review.&nbsp;Systematic Reviews,&nbsp;7(1). <a href="https://doi.org/10.1186/s13643-018-0882-7">https://doi.org/10.1186/s13643-018-0882-7</a>.&nbsp;</li>
<li>World Health Organization. (2001). World Health Report 2001: Mental Health: New Understanding, New Hope. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</li>
<li>World Health Organization. (2017). Creating mental health and related services free from coercion, violence, and abuse &ndash; WHO Quality Rights training to act, unite and empower for mental health. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<a href="https://apps.who.int/iris/bitstream/handle/10665/329582/9789241516730-eng.pdf">https://apps.who.int/iris/bitstream/handle/10665/329582/9789241516730-eng.pdf</a>&nbsp;</li>
<li>World Health Organization Regional Office for the Eastern Mediterranean. (n.d.). Egypt Mental Health. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<a href="http://www.emro.who.int/egy/programmes/mental-health.html">http://www.emro.who.int/egy/programmes/mental-health.html</a>. Accessed 15 Aug 2020.&nbsp;</li>
<li>World Health Organization Regional Office for the Eastern Mediterranean. (2017). Guide to health gap program interventions for mental, neurological, and addictive disorders in non-mental health care settings. [Dalil tadakhulat barnamaj ra&rsquo;b al-fajwat fi al-sihat li-l-iditrabat al-nafsiyat wal-&rsquo;asabiyat wa-l-admaniyat fi mawaqie&rsquo; taqdim alrieayat al-sihiyat gheyr al-nafsiya]. [In Arabic]. Geneva: World Health Organization;&nbsp; <a href="https://applications.emro.who.int/docs/EMROPUB_2019_2606_AR.pdf?ua=1">https://applications.emro.who.int/docs/EMROPUB_2019_2606_AR.pdf?ua=1</a> Accessed 15 Aug 2020.</li>
</ul>

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