The optimal psychiatrist-to-population ratio: a Canadian perspective

Progress towards universal health coverage in the context of mental disorders in India: evidence from national sample survey data

BACKGROUND

Universal health coverage (UHC) has emerged as one of the important health policy discourses under the current sustainable development goals in the world. UHC in individual disease conditions is a must for attaining overall UHC. This study measures progress towards UHC in terms of access to health care and financial protection among individuals with mental disorders in India.

METHODS

Data from the 75th Round National Sample Survey (NSS), 2017-18, was used, which is the latest round on health in India. Data collected from 555,115 individuals (rural: 325,232; urban: 229,232), from randomly selected 8077 villages and 6181 urban areas, included 283 outpatient and 374 hospitalization cases due to mental disorders in India. Logistic regression models were used for analyses.

RESULTS

Self-reporting of mental disorders was considerably lower than the actual disease burden in India. However, self-reporting of ailment was 1.73 times higher (95% CI: 1.18-2.52, p < 0.05) among the richest income group population compared to the poorest in India. The private sector was a major service provider of mental health services with a larger share for outpatient (66.1%) than inpatient care (59.2%). Over 63% of individuals with a mental disorder who reported private sector hospitalization noted unavailability or poor service quality at public facilities. Only 23% of individuals hospitalized had health insurance coverage at All India level. However, health insurance coverage among poorest economic class was a meagre 3.4%. Average out-of-pocket expenditure during hospitalization (public: 123 USD; private: 576 USD) and outpatient care (public: 8 USD; private: 37 USD) was significantly higher in the private sector than in the public sector. Chances of facing catastrophic health expenditure at 10% threshold were 23.33 times (95% CI: 10.85-50.17; p < 0.001) higher under private sector than public sector during hospitalization. Expenditure on medicine, as the share of total medical expenditure, was highest for hospitalization (public: 45%, private:39.5%) and outpatient care (public: 74.1%, private:39.7%).

CONCLUSIONS

Social determinants play a vital role in access to healthcare and financial protection among individuals with mental disorders in India. For achieving UHC in mental disorders, India needs to address the gaps in access and financial protection for individuals with mental disorders.

TRIAL REGISTRATION

Not applicable.

Cost estimation for the implementation of the Mental Healthcare Act 2017

The Mental Healthcare Act, 2017 (MHCA) was a step that was essential, once the Government of India ratified the United Nations Convention on the Rights of Persons with Disabilities in 2007. The MHCA looks to protect, promote, and fulfill the rights of persons with mental illness (PMI) as stated in the preamble of the Act. Further, there is an onus on the state to provide affordable mental health care to its citizens. In India, mental health has always been a lesser priority for lawmakers and citizens alike. The rights-based MHCA looks to overhaul the existing system by giving prominence to autonomy, protecting the rights of the mentally ill individuals, and making the State responsible for the care. The decision to make all this happen is commendable. The annual health expenditure of India is 1.15% of the gross domestic product, and the mental health budget is <1% of India's total health budget. This article systematically analyses and describes the cost estimation of the implementation of MHCA 2017, and it is not an estimation of mental health economics. The conservative annual estimated cost on the government to implement MHCA, 2017 would be 94,073 crore rupees. The present study estimation depicts that investing in the implementation of MHCA, 2017 by the government will yield 6.5 times the return on investment analysis benefit. If the State is not proactive in taking measures to implement the MHCA, the rights promised under this legislation will remain aspirational.

The impact of generational change and retirement on psychiatry to 2025

BACKGROUND

Australia is currently experiencing widespread shortages of psychiatrists. The changing nature of the workforce and increasing demand mean that these shortages are unlikely to ease. This study aims to identify demographic change and retirement patterns of the Australian psychiatry workforce from 1995 to 2003, and the implications of those changes for future workforce planning.

METHODS

Data from the Australian Institute of Health and Welfare (AIHW) Medical Labour Force Survey from 1995 to 2003 is used to examine ageing of the psychiatry workforce and attrition of psychiatrists aged 50 years and over. Future attrition from the workforce is projected to 2025.

RESULTS

Sixty two percent of psychiatrists practicing in the year 2000 are predicted to have retired by 2025. Most psychiatrists continue to work until late in life, with only 18 per cent retiring before age 65. The psychiatry workforce aged significantly between 1995 and 2003 (p < 0.001), with men older than women in both years. A reduction in hours worked by psychiatrists reflects both the increasing proportion of females and the older members of the profession reducing their hours in preparation for retirement.

CONCLUSION

The impact of ageing of the workforce may be more immediate for psychiatry than for some other health professions. With the growing proportion of females and their typically lower workforce participation, more than one younger psychiatrist will be required to replace each of the mostly male retirees.

The mental health professions: workforce supply and demand, issues, and challenges

The U.S. mental health (MH) workforce is comprised of core disciplines: psychology, psychiatry, social work, psychiatric nursing, and marriage and family therapy. A broader group of practitioners also deserves recognition. Diverse professions provide significant services in a variety of settings, extending the de facto mental health workforce. A tally of key disciplines estimates there are 537,857 MH professionals, or 182 per 100,000 U.S. population. This article provides an overview of the need and demand for mental health services and summarizes the MH professions (e.g., training, educational credentials, workforce estimates). It also discusses a range of challenges confronting MH professionals and the need for greater understanding of the workforce and integration of services. Methodological factors that confound estimates of the magnitude of the MH workforce are reviewed.

Child psychiatry practice patterns in Ontario

OBJECTIVES

To examine the demographics, training, distribution, venues of practice, remuneration patterns, and professional affiliations of child psychiatrists in Ontario.

METHOD

In July 1997, questionnaires were sent to 229 Ontario psychiatrists. A second mailing was sent to nonresponders in the fall of 1997. The overall response rate was 66.8%.

RESULTS

Compared with other research regarding the ratio of child psychiatrists to children with mental health problems, Ontario fares relatively well (1:6148). Generally, Ontario child psychiatrists report having received formalized training in the speciality. Child psychiatrists are disproportionately concentrated in Toronto and in midsize cities with medical schools compared with rural regions. Out-reach services to smaller communities are provided by 30% of child psychiatrists, but it is not clear whether the services are sufficient and equitably available. Approximately 50% of current psychiatrists will be aged 65 years or older in 15 years, and it is unclear whether sufficient numbers will replace them. The profession appears to be reaching an equitable gender representation. Most child psychiatrists belong to the professional organizations that support the profession; however, they are least likely to belong to the Ontario Psychiatric Association (OPA).

CONCLUSIONS

An optimal ratio of child psychiatrists per population served still needs to be determined, with special consideration given to the needs of rural communities. The small ratio of child psychiatrists to the population of children with mental health needs highlights the importance of collaborating with other medical and mental health professionals. Recruiting and retaining child psychiatrists will need to be monitored. Child psychiatrists in Ontario need a unified voice to address these issues.

Physician resource variables and their impact on the future pool of research expertise among psychiatrists: the Canadian Association of Professors of Psychiatry and Canadian Psychiatric Association Survey

OBJECTIVE

To assess the impact of the increased proportion of female psychiatrists and trainees, the rapid reduction of international medical graduates allowed in the country, and the expanding number of practitioners with subspecialization on the future pool of psychiatrist researchers in Canadian academic departments of psychiatry.

METHOD

A questionnaire was adapted to suit the Canadian milieu and distributed to a target population of 2484, including a core of 522 full-time faculty.

RESULTS

Female psychiatrists responding to the questionnaire reported less research involvement overall than their male counterparts. International medical graduates with both undergraduate and residency training abroad reported more research interests than other graduate categories. Respondents training in a subspecialty showed no difference in research commitment.

CONCLUSIONS

Concerted efforts must be made to recruit, support, and retain female researchers. Particular attention must be paid to developing research expertise among Canadian medical graduates. The trend towards subspecialization influences only the selection of research topic.

What Are We Training For? : A Follow-up Survey of a Child Psychiatry Training Program

The authors report the results of a 1990 survey of 91 graduates of the 2-year training program in child psychiatry at the University of Toronto. The participants, who completed their training between 1982 and 1989, completed a structured questionnaire designed to assess current patterns of practice, consultation, and academic activities. The respondents were also asked which aspects of their training were relevant to their current practice and what topics would be of interest for continuing medical education. The implications of the results for planning child psychiatry training curricula are discussed. (Academic Psychiatry 1994; 18:88-94).

Consultation-liaison psychiatry as a subspecialty. A Canadian survey

In Canada, in recent years, there has been increased interest in the issue of subspecialization in psychiatry. One hundred and forty-four members of the Section on Psychosomatic Medicine of the Canadian Psychiatric Association responded to a survey about their opinions on teaching, training, continuing education, and designation of consultation-liaison (C-L) psychiatry as a subspecialty. Fifty-five percent of respondents agreed that C-L psychiatry should receive designation as a psychiatric subspecialty, 35% were opposed, and 10% did not give an opinion. The results also indicated that formal teaching in C-L psychiatry has increased, particularly over the past 20 years; that training in C-L psychiatry is believed by many to have been inadequate, regardless of when the training took place; and recent graduates were more likely than psychiatrists graduating more than 10 years ago to agree that C-L psychiatry should be designated as a subspecialty. Psychiatrists who devote more of their time to the care of patients with combined medical and psychiatric illness were also more likely to favor subspecialty designation. Factors unique to Canada that may influence attitudes toward psychiatric subspecialization include the number and geographic distribution of psychiatrists, their educational background, and governmental funding priorities.

The geographical distribution of psychiatrists in Canada: unmet needs and remedial strategies

Many efforts are underway to rationalize the process of manpower planning in psychiatry. A wide variation in the geographic distribution of psychiatrists remains. A multidimensional assessment of the needs of a population is recommended, based on the epidemiology of mental disorders, professional and institutional needs, consumer estimates, and the requirements of subgroups. Counting the number of vacant positions for psychiatrists can be misleading. Professional norms for the optimal access of a population to psychiatric services and standards for the quantity and/or quality of services provided need to be developed. Potential outcome measures are suggested, along with a three-tiered system of estimating geographic needs. Deterrent factors to an optimal geographic distribution of most professionals are reviewed, along with factors specific to our residency training programs. In the short term, the benefits and limitations of recruiting foreign-trained psychiatrists are compared with those of recruiting Canadian specialists. Complementary long term strategies include the provision of financial incentives, optimal working conditions, relevant training and maintenance of competence issues, and community support.