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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 • • • • • • • • • • • • • • • 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