Download Economic Burden of Mental Health In Pakistan

17th National Health Sciences Research Symposium,
AKU
February, 2014
Economic Burden of Mental
Health In Pakistan
Murad M Khan, Dept. of Psychiatry
M Ashar Malik, Dept. of CHS
Aga Khan University
Mental health
• Mental illnesses pose most serious threat to the
health systems as a factor contributing to other
illness
• Mental illnesses are the major contributor to the
economic losses in economic burden of diseases.
• Mental health problems commonly goes unnoticed and unaccounted in national priority
settings
Burden of diseases worldwide: Disability adjusted
life years (DALYs), 2001
Prevalence of Major Depression in patients with physical
illnesses
WHO, 2003
The overall economic burden of mental disorders
WHO, 2003
Types of measurable costs
WHO, 2003
Costs in adulthood of child mental health
problems (additional costs from 10-27 years (£)
Economic burden of mental ill-health
• Range of costs on individuals, households,
employers & society as a whole.
• Developed countries: cost of mental health
problems is between 3% and 4% of GNP.
• Ability of ill persons & caregivers:
–
–
–
–
–
Personal income
To work
Productivity in workplace
Contributions to national economy
Utilization of treatment & support services
How much does mental illness cost?
• United States (1990): US$ 148 billion.
– Indirect costs either match or out- weigh direct
costs for all mental health areas.
• Canada (1998): Can$ 14.4 billion
– Can$ 8.1 billion in lost productivity
– Can$ 6.3 billion for treatments
• United Kingdom (1996/97)
– Aggregate cost: £32 billion
– 45% due to lost productivity.
Mark et al., 2000; Stephens & Joubert, 2001; Patel & Knapp, 1997
Mental Health Gap
• Enormous gap between need for treatment of
mental disorders and resources available.
• In developed countries:
– 44% and 70% of patients do not receive treatment.
• In developing countries:
– Treatment gap being close to 90%.
Annual cost/case (or episode) of evidence-based psychiatric treatment
Cost per treated case (in international dollars, I$)
WHO, 2003
Share of mental health budget in total health budget of
countries by income level (%) (World Bank classification)
WHO, 2003
Poverty & mental disorders: a vicious cycle
Mental health: Pakistan
• On rise due to:
– Adverse social conditions
– Political instability
– Decade long war on terrorism
– Repeated natural calamities
– Reformation & transition of economy.
Common Mental Disorders (CMDs)
N. Pakistan
Women
Men
TOTAL
40-60%
15-33%
37%
66-72%
25-44%
51%
42.2%
18.1%
30%
25-36%
10-18%
22%
57.7%
25.5%
42%
20%
13.2%
17%
50%
32%
50%
Mumford (1996)
Rural, Punjab
Mumford (1997)
Urban, Karachi
Ali (1999)
Urban, Punjab
Mumford (2000)
Rural, Punjab
Husain (2000)
Urban, Karachi
Kidwai, (2013)
Urban, Karachi
(elderly)
Bhamani (2013)
Mental Disorders: prevalence (est.)
• SMIs: 0.5-2% (0.4- 1.7 million)
• Drug addicts: 1-3 million
• Child MH Dis: 10% (9 million)
• Others
– Psychosomatic disorders?
– Psychiatric sequelae of RTAs/injuries?
Suicide: Pakistan (est.)
• Suicide: 6000-8000/year
• DSH: 60,000- 160,000/year
• Suicidal ideation: 600,000- 800,000/year
• Every suicide: affects at least 6 other
people
Mental Health budget
• Health budget: <1%
• Mental health
– No separate budget
– 1% of health budget!
• Issues
– Governance/corruption
• Mental Health Act, 2001
– Not implemented
Karachi: In-patient charges/day (in Rs.)
General
Semi- Private
Private
Charges *
Min.
Max.
1500
3000
3000
4000
5000
7000
*Food, medicines, doctor fees, tests- extra
Karachi: Consultation Charges
Initial
Min.
Psychiatrists
Psychologists
Counselors
Occupational Therapy
Social Workers
Speech & Language
Therapy
Special Educators
Max.
150
3000
150 8000*
1000 10000*
700
1000
2000 2000
150
1500
500
2000
* Multiple sessions for assessment + report writing
Follow-up
Min.
Max.
150
200
1000
675
2000
2000
6000*
5000*
810
2500
500
500
1200
2000
Dept. of Psychiatry, AKUH
• Cost of illness study
• Secondary data
• Hospital Information Management
System (HIMS-AKUH)
• Average attendance (2005-06)
– Ambulatory : 14,000/yr
– Admissions: 450/yr.
Methodology
• 2005-06: Psychiatry
– Hospital admissions & ambulatory care
• Stratified random sample drawn for both.
– Ambulatory care: n= 1240
– Admissions: n= 642
• Sampled observation retrospectively followed for
socio-economics & prescription medications.
• Information generalized to whole data to
estimate annual economic burden for each type
of mental illness.
Methodology
• Data on:
– Age, gender, marital status, profession, ethnicity,
education
– Primary & secondary diagnosis
• Costs included:
– Ambulatory care: cost of consultation, medicines,
travel cost, caregiver time, productivity losses
– Admissions: cost of consultation, medicines,
procedures, laboratory, bed charges, food, travel,
caregiver time, productivity losses
Results
Ambulatory Care (2005-06)
Diagnosis
Frequency
Percent
Male (%)
Dementia and Organic Disorder
47
3.79
59.6
Schizophrenia/Psychotic D.
154
12.42
63
Mood Disorders
724
58.39
49.6
Anxiety panic OCD
170
13.71
58.2
Acute Stress Reaction/Adjust: disorder
49
3.95
20.4
Personality Disorders
15
1.21
66.7
Eating Disorders
3
0.24
33.3
Substance Abuse
29
2.34
75.9
ADHD
35
2.82
91.4
Psychosexual dysfunction
10
0.81
80
Sleep disorder
4
0.32
100
Total
1240
100
54
Ambulatory: Cost (Rs.) n=1240
Diagnosis
Healthcare
costs
Productivity
losses
Total costs
Dementia and Organic Disorder
Schizophrenia
Mood and Depressive disorder
Anxiety panic/ OCD
ASR/AD
Personality D
Eating D
Substance abuse
ADHD
Psychosexual dysfunction
Sleep disorder
85,205
511,356
2,693,119
610,987.1
223,950.9
84,517.9
11,016.1
157,210.4
326,090.8
52,949.3
7,669.2
305,841
471,224
1,340,0000
339,2849
184,089.7
6,3847
1,350
972,960.1
1,5750
24,082.12
1,1188
391,086
982,940
1,610,0000
400,3986
40,8080
148,365
1,2366
113,0251
34,1841
7,7031
18,857
Total
4,764,072
18,800,000
23,600,000
Admissions (2005-06)
Diagnosis
Frequency
%
Median
LoS (days)
Dementia & Organic Disorders
16
2.5
4
Schizophrenia
197
30.7
7
Mood Disorders
334
52
6
Anxiety Disorders
20
3.1
4
ASR/AD
32
5
2
Personality Disorders
9
1.4
6
DSH
2
0.3
2
Eating Disorders
2
0.3
5
Subs. Abuse/Sexual Dys.
30
4.7
6
642
100
6
Total
Hospital Admissions: Cost (Rs.) n=642
Diagnosis
Healthcare Productivity
costs
losses
Total costs
Dementia & Organic Disorders
1,84,668
462855
676083
Schizophrenia
53,77,013
10000000
16200000
Mood Disorder
6,581,615
16,800,000
24,300,000
Anxiety/Panic/OCD
3,54,065
676090
1084115
ASR/AD
2,93,119
785630
1113985
Personality Disorders
2,23,097
210756
456722
DSH
52,431
27792
84216
Eating Disorders
30,274
66624
100398
5,24,230
2133768
2684098
13,600,000
31,200,000
46,600,000
Sub. abuse/Sexual Dys.
Total
Cost/episode of illness: Ambulatory (Rs.)
Diagnosis
Medicine Total Cost
Cost
Dementia/Organic Disorder
396
1101
Schizophrenia
1303
1802
Mood Disorders
2436
2506
Anxiety/Panic/OCD,
4060
2153
ASR/AD
2777
1805
Personality Disorders
4478
1104
Eating Disorders
586
2503
Substance Abuse
440
2155
ADHD & Speech Difficulties,
10264
2858
Sexual Dysfunction
6673
3206
2300
2503
Total
Cost/episode of illness: Admissions
Diagnosis
Consultation Bed Medicines Total
Charges
Cost
Dementia & Organic Disorder
1950
5740
492
10,132.71
Schizophrenia
3510
10490
1644
19,210
Mood Disorders
2940
8760
1509
15,602
Anxiety/Panic/OCD
1710
5210
750
13,353
ASR/AD
840
3015
572
5846
Personality Disorders
2760
8000
861
12,782
DSH
6710
17040
719
26,002
Eating Disorders
2640
8760
632
18,422
Substance Abuse/Sexual Dys.
2690
8197.5
797
13,479
2940
8760
1374
15,603
Total
Cost of treatment of DSH: AKU (2004)
• Presenting to ER: 98 patients
– Admitted: 34
– Discharged/LAMA: 64
• Mean cost/patient
– Admitted: US$ 255 (Rs. 26,775)
– Discharged/LAMA: US$ 55.6O (Rs. 5775)
Cost of treatment of DSH: Pakistan
• DSH: 60,000-160,000 (est.)
• Rs. 5000/episode
• Cost: Rs. 34,650,000- Rs. 80,000,0000
Pakistan: cost of mental healthcare
(2006)
• Assuming
– A 10% prevalence of mental illness in population
(170 million)
– A 50% health seeking from healthcare providers
– Average healthcare cost of Pak Rs. 2300/ episode
– Sum of Pak Rs. 19.55 billion would have
probably been spent on treating mental illness in
Pakistan in 2006
AKUH: generalizability of results?
• Cost of consultation may be negligible in public
sector health facilities
• Medicine cost might be same as low priced
generic psychotropic medications are used at
AKUH
• Quality of care, practice variation & unofficial
payments might pull the cost of mental health
closer to our estimates
Mental Health Gap
• Relationship between burden of mental
disorders & spending is clearly inappropriate
• Wide gap between burden of MH disorders
& MH budget
• Urgent action needed
– Close treatment gap
– Overcome barriers which prevent people from
receiving appropriate care.
Summary & recommendations
• Cost of mental healthcare: high
• Role of mental health should be acknowledged in
national economic policies due to huge
productivity losses
• Health policy should re-orient its priorities:
– recognize mental health management at primary
healthcare level
• Mental health promotion & preventive programs:
– more cost effective than spending on healthcare
• More research
Karachi’s black economy
generates Rs. 830 million every day
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Extortion:
Kidnapping for ransom:
Parking mafia (500 lots):
Hawkers (55,000):
Water mafia (272 m):
Drugs/gambling dens:
Land mafia:
Transport mafia:
‘Dhakka Wasooli’:
Electricity theft (Kundas):
Health sector:
Vehicle theft:
Street crime:
Short term kidnapping:
Payment to police:
Sept 4, 2013
Rs. 10 million
RS. 50 million
Rs. 2.4 million
Rs. 8.25 million
Rs. 100 million
Rs. 150 million
Rs. 7 Billion annually (Rs. 230m/day)
Rs. 10.48 million
Rs. 7.5 million
Rs. 10.5 million
Rs. 3 million
Rs. 20.5 million
Rs. 5.2 million
Rs. 3 million
Rs. 210 million
What should we invest in?
Cost of F16 = US$ 20 million
Rs. 174,0000000