Mental health services in the Arab world

Arab Studies Quarterly (ASQ), Fall, 2003 by A. Okasha .left { float: left; } .right { float: right; } .fa_inline_ad { margin-top: 0; text-align: center; margin-bottom: 20px; margin-right: 10px; } #fa_square_ad.right { margin-top: 20px; margin-left: 20px; } html* #fa_square_ad.right { margin-top: 60px; float: none; } .fa_inline_ad h4 { margin: 0; font-size: 8pt; color: #666; text-transform: uppercase; textalign: center; font-weight: normal; font-style: normal; } .fa_inline_ad ul { list-style-type: disc; list-style-position: inside; color: #3769DD; border-top: 1px dotted #333; padding: 5px 0 0; margin: 0 0 20px; } .fa_inline_ad ul li { margin: 0; padding: 0; } /* Fix for IE */ .mostPop { float: left; } .fa_inline_results.left { clear: none; } INTRODUCTION THE ARAB REGION HAS A POPULATION of 275 million with the highest population density being in Egypt. Despite several similarities that characterize our countries as a "homogenous" region with overlapping problems and challenges, yet mental health issues and services show several variations. Some Arab countries enjoy the highest income per capita, yet this is incompatible with the quality of mental health services available there. The per capita mental health services, the availability of a mental health act, the space allocated for mental health in medical curricula and the nature of the mental health challenges as identified by mental health professionals in the different Arab countries are but a few of the concerns that should be addressed in a review of the situation. MENTAL HEALTH CHALLENGES Large-scale community surveys are scarce in the Arab world. Despite the available resources that exist in the Arab countries collaborative multi-national cross-sectional and longitudinal studies have not been produced. However, there is lack of reliable epidemiological psychiatric base line data. This is partly related to the very concept of mental disorder itself, which may vary widely in divergent cultures (Ghubash and ElRufaie, 1997), and to the methodological problems of assessment and evaluation. There is scarcity of valid, reliable and culture relevant Arabic psychiatric research instruments. There are doubts about the scales, which were originally designed for use in other cultures, due to problems relating to the linguistics and conceptual equivalence (ElRufaie and Daradkeh, 1997). In view of the above restrictions, Okasha & Karam 1998 conducted a mail survey to a number of colleagues in Arab countries investigating several aspects of mental health problems and resources. The outcome indicated that Arab countries seem to overlap in several of their concerns and expressions of mental health needs. Responses showed a consensus about the need for public mental health education, increasing the number of psychiatrists, upgrading the training and education of mental health professionals, the development of preventive and curative community mental health care services and the development of a mental health act.

As to mental health challenges, the development of rehabilitation services was a need expressed by the input from Bahrain, Jordan, Lebanon and Tunisia. Special education schooling children with learning disabilities and mental retardation was reported from Egypt, Jordan, Lebanon, Saudi Arabia, Tunisia and UAE. Children in the Arab World constitute around 45 percent of the total population. The awareness about psychosocial development of children and adolescent is lacking among the majority of parents and teachers. A study done by Seif El Din et al. (1998) in Egypt portrayed the number of pre-school children having behavioral problems was nearly one fourth of the total sample (23.35%) and fifty percent of them reported having temper tantrums, followed by sleep problems, mainly difficulty in sleeping on their own and over activity. A school based study carried out in Saudi Arabia, reported that 13.4 percent of school boys suffered from behavioral and or emotional disorders, (6.9% were behaviorally disturbed, 5.5% were emotionally disturbed and 0.7% were mixed disorders (Abol Fotouh, 1996). In Alexandria, Egypt the prevalence of behavioral and emotional problems among pre-school children attending nurseries was estimated to be 22.5% (Abdel Latif et al., 1989). Available services are limited in comparison to the adult psychiatric services In Egypt, Lebanon, UAE and Morocco there was a need for the development of drug abuse programs considering the rising prevalence of drug abuse, especially among the young (Table 1). Compared to developed countries, the types of drugs widely used in our part of the world are mainly either central nervous system depressants or hallucinogens. Both point to drug taking in our culture as means of an escape from rapid societal upheaval during a phase of national change and from stability and conservatism to an unknown contemporary modern society. Available models of developed societies are threatening and frightening for a nation that had a historical backlog of civilization. The nation is negotiating an identity crisis hand in hand with challenges of development (Akabawi, 2001). Lebanon, UAE and Morocco expressed the need for child and geriatric services. Colleagues from Egypt, Jordan and Tunisia explicitly referred to a shortage in epidemiological research in mental health and disease. Community psychiatric surveys are an essential part of psychiatric epidemiology. They inform us about the need for services and whether these are changing; they allow us to examine disorders without the distortions of the referral process; they permit the identification of high-risk groups, and they enable us to examine the influence of important social and cultural factors (Ghubesh, 2001). The clinical presentation of mental disorders in our region constitutes one challenge that requires special consideration, since it reflects on both the training needs and the facilities mostly commonly used by our patients. Seventy to 80% of psychiatric patients in developing countries tend to somatize their emotions and express their feelings in physical symptoms. Like the majority of developing countries, many mental patients in Arab countries tend to somatize their psychological symptoms. This tendency to somatization seems to protect the patient from the stigma of mental illness, but on the other hand it also leads him or her initially to consult with a traditional healer, general practitioner or an internist rather than a psychiatrist, i.e., this presentation of mental ill-

health reflects on the pattern of consultation and should be taken into consideration in the design of mental health policies and programs. According to Goldberg and Huxley (1992) patients tend to pass through different health care providing filters before they reach our clinics and hospitals. Out of every 1000 citizens 315 have psychiatric symptoms, 230 go to GP, 101 are identified and diagnosed, 17 are referred to the psychiatrist and only 6 are admitted to hospital, i.e., almost twothirds of patients with psychiatric symptoms would first go to the general practitioner and of those only 50% would be recognized as having a psychiatric disorder. The real challenge for mental health professionals is the first filter, i.e., patients realizing their mental health problems. This challenge, however, cannot be met without a reorganization of the health providing structures and the approach to medical education and training, and the latter cannot be systematically approached without the guidance of action oriented and policy oriented research. A most challenging component at the level of the first filter is role played by traditional healers in our countries. Cultural beliefs of possessions and the impact of sorcery or the evil eye affect our patients' interpretation of mental symptoms. In this context the first resort for the families of mental patients is not necessarily even the GP, but the traditional healers who acquire a special importance because of their affiliation to the community and their claim of dealing with the "mystical," the "superstitious" and the" unknown," all of which are still powerful cognitive constructions in our region. In all Arab countries traditional healers constitute a component of the informal and sometimes unofficial health care providers that cannot be overlooked. But how do they relate to the medical profession in different contexts? In the majority of Arab countries there is no interaction between the medical profession and the traditional healers. In Jordan there is some kind of a relationship, which, however, remains informal and unorganized. In Saudi Arabia, on the other hand, they constitute part of the staff, using religious text and recitation in management. It is interesting to note that several of the responses we received differentiated between traditional healing based on religion and that based on popular conviction in ghosts, jinns and possessions. The differentiation also indicated a potential acceptance of the first and rejection of the second. Whether we like it or not traditional healers do and will continue to provide some form of intervention into the lives of mental patients and their families and this is more likely the case with less accessibility to mental health services on the community level. Emphasis should therefore be given to the study of the positive and negative impacts of traditional practices. In Egypt, they deal with minor neurotic, psychosomatic, and transitory psychotic states using religious and group psychotherapies, suggestion, and devices such as amulets and incantations. It was estimated that 60% of outpatients at the university clinic in Cairo serving low socio-economic classes have been to traditional healers before coming to the psychiatrist (Okasha et al., 1993). The Arab family is the main social institution that has inputs relevant to clinical psychiatry. It contributes much more than the Western family to mental development, illness behavior, illness pattern and illness management. The roles of schools and out-of-

home care institutions are more significant in the West. Recent budget realignments in Western countries drastically compromised their social welfare system, and services for the elderly, the poor and the sick had to be taken over by "someone else." Western mental health professionals rediscovered the role of the family in this respect, which had long been abandoned for the sake of individuation of human beings. The family care, which was phased out through industrialization and communism alike, is now actively re-sought (El Islam 1998). The Arab family runs the affairs of its healthy and sick members alike. Although extended family households have been largely replaced by nuclear families, the latter have maintained a 'functional' extended family by frequent visits, telephone contacts, business and property partnerships and arrangement of marriages within their bigger family network. The functional extended family provides substitutions for parental loss or absence, mediation in conflicts (including marital and intergenerational conflicts), preferential (nepotistic) employment of kin and help with expenses of health care. The fore-care and after-care of the sick are family responsibilities in Arab countries (El Islam 2001). SOCIAL AND RELIGIOUS DYNAMICS The Islamic code of conduct describes the course of action or "standard practice" for human-to-God and human-to-human relationships in everyday life. It comprises a system of criteria that separates rightful from wrongful behavior and is therefore an important yardstick for the demarcation of behavioral abnormality among Moslems, the majority of Arabs. Members of the young generation, however, tend to be less adherent to this code than the parental generation. In rapidly changing Arab communities e.g., in the Gulf region, intergenerational conflict and strife impair the normal family function in solving stressful situations. Individuals who have socially unconventional behavior e.g., drinking alcohol, premarital sexual practice or the nonobservance of public rules for the fasting month may be taken to psychiatrists by their family elders in some Gulf communities for assessment of their mental state. The psychologization of their social deviance (El Islam 1998) not only preserved a facade of adherence to the Islamic code but also avoided the punishment of code breakers by the legal system based on this code and saved the family the shame and inability to arrange the marriages of code breakers. Belief systems in the Arab world are derived from Islamic and non-Islamic roots. Some pre-Islamic beliefs continued to thrive after the inception of Islam e.g., beliefs related to the subordinate status of women. Other beliefs were imported and adopted by Moslems from non-Islamic communities (para-Islamic beliefs) e.g., beliefs related to the adversity of Zar demons to humans. Still other beliefs entertained by present day Arabs (neeIslamic beliefs) have been introduced by Arabs in post-prophetic eras e.g., beliefs that dead sheiks of religion could bless or help those who invoke their support by visiting their shrines. (El Islam 1999) Islamic belief systems include beliefs in the adversity of certain supernatural agents e.g., the devil, the jinn or the envying evil "eyes" of some human beings. The devil is believed

to endeavor to tempt humans, especially those with weak faith, to forget their religious observances, to have anti-religious thoughts (or religious doubts) or to diverge from the Islamic code of conduct. Arab psychiatrists can recognize the obsessional character of anti-religious thoughts and doubts and distinguish their patient's Schneiderien passivity symptoms from socially shared beliefs of being 'made' to do wrong things by the devil as the former axe beyond the putative spectrum of the latter (Al Ansari et al 1989). MENTAL HEALTH SERVICES Service providers Health services in all Arab countries are provided by public (government) and private sector facilities. In some countries insurance systems contribute to the provision of the service. The proportion of the use of the different health providers varies from one country to the other depending on the prevailing economic policies. Non-governmental organizations have come to be recognized as an important actor in the provision of health services, especially in countries with internal instability. In Lebanon NGOs were prominent in the late 80s because of the internal instability, but their role has diminished since 1990, when the large scale wars ended. In Palestine, the absence of a state and, consequently, a stable government, has led to a situation where NGOs continue to play a major role on the provision of health services to the people. With the introduction of structural adjustment policies and the gradual withdrawal of third world governments from the subsidy and support of health services, cost recovery and fee for service systems are gradually replacing the free service provision. Insurance schemes work only for citizens who are employed by an institution which provides health insurance. Outside those umbrellas citizens are expected to buy their health service; in many occasions this results in the neglect of medical consultation. MENTAL HEALTH RESOURCES According to WHO estimates, the public expenditure on mental health should not be less than 10 percent of the total health budget. Seventy-five percent of the services should be equally distributed over the different regions of the country; 25 percent of general hospital beds should be allocated to mental patients and the nearest mental health facility should not be more than an hours drive from potential users. Recommended WHO figures include 0.25-1 psychiatrists per 10,000 population and mental health beds in the ratio of 5 to 8 beds per 10,000 citizens (WHO, 1996). WHO estimated the average need for mental health beds to be the following:
DURATION OF STAY up to six months 6 months to one year one-two years 2-three years NO. PER 100,000 POPULATION 3.3 1.6 1.6 1.3

The following paragraphs outline the status in Arab countries. Mental Health facilities (Table 2)

In all Arab countries the ratio of psychiatric beds to population leaves much to be desired. The priorities for community health care services in Egypt are not for mental health, but rather for more endemic health problems. Malnutrition, parasitic infestations, maternal and child morbidity and drug abuse are more important priorities and reflect on the allocation of resources for mental health services. The programs for community care in big cities take the form of outpatient clinics, hostels for the elderly, institutions for the mentally retarded, and centers for drug abuse, school and university mental health. Egypt has about 9,000 psychiatric beds, one bed for every 7,000 citizens, i.e., 15beds/100,000 populations. The number of psychiatric beds in Egypt constitutes less than 10% of the total hospital beds (110.000). The largest two mental hospitals in Egypt face great difficulties regarding care, finances, treatment, and rehabilitation while accommodating about 5,000 patients (Okasha A, 1993). The new policy of deinstitutionalization and provision of community care may reduce the number of psychiatric in-patients but will not solve the problem (Okasha 1988). Aftercare services in Egypt are still limited due to poor understanding of most people for the need of follow-up care after initial improvement. Community care in the form of hostels, day centers, rehabilitation centers and health visitors is only available in big cities. In Jordan psychiatric beds are distributed between general hospitals and military hospitals, and there are no psychiatric beds in university hospitals. In Palestine there are two psychiatric hospitals, one in Bethlehem with 320 beds serving 1,450,000 in the West Bank, which gives a rate of 0.04 beds per 1000 population. In Gaza the psychiatric hospital contains 32 beds and serves the population of Gaza strip, which reached 800,000 in 1993. Besides the hospitals the Palestinian mental health services include many NGOs most of which were established during the Palestinian uprising. Table 2 shows an overview of the number of psychiatric hospitals and beds in the different Arab countries. MENTAL HEALTH TEAM Although the stigma of mental illness and consequently of the mental health profession is gradually being reduced in Arab countries, in view of the public campaigning for psychiatry as a branch of medicine in addition to the boom of psychotropics with favorable outcomes for previously "incurable" disorders, however, the number of professionals who work in the field of psychiatry is still far below that needed to meet with the mental health needs in a developing region like ours. The ratio of medical doctors to population is highest in Lebanon and lowest in Tunisia, while the best population/nurse ratio is found in Tunisia (Table 3). Egypt has the highest number of psychiatrists, about 1,000 psychiatrists, one for every 66,000 citizens (WHO standard is 1 for 10000 population); it has about 211 clinical psychologists, with hundreds of general psychologists working in fields unrelated to the mental health services. There are many social workers practicing in all psychiatric facilities, but

unfortunately they are generic social workers with minimal graduate training in psychiatric social work. An attempt was made in the 1960s to educate psychiatric social workers at the institute of Social Services in Cairo. Due to the low number of applicants the program was discontinued after two years. Table 4 shows the numbers of trained psychiatrists and their ratio to their populations and the numbers of other members of the mental health team in some Arab countries. EXPENDITURE ON HEALTH According to the WHO World Health Report (2001) the health expenditure estimated as percentage of gross domestic product is highest in Lebanon (11.3%) followed by Jordan (8.8%), Tunisia (5.3%) and Bahrain (5%). None of the remaining Arab countries fulfilled the WHO recommendation of a minimum expenditure of 5% of GDP on health. In none of the sources could we find a reference to the specific expenditure on mental health services. It may also be interesting to compare the expenditure on health and education in this region with the expenditure on the military, to realize the impact of political tension on the status of the basic services. Military expenditure as a percentage of expenditure on health and education is lowest in Algeria (11%), and reaches up to 271%, 293% and 373% in Iraq, Oman and Syria respectively. In a different political context, a reallocation of those budgets could change the health map in the region to more favorable standards (UNDP, 1995). Mental health problems constitute 12% of the global distribution of health burden (1999) as measured by the percentage of Disability Adjusted Life Years (DALYs). Depression is ranked the second in developed and the fourth in developing countries (DALYs 1999) among the ten most frequent diseases in the world causing disability. Depressive disorders represent the highest percentage of disability among mental disorders 17.3%), with psychosis 6.8%, drug dependence 4.8%, Alzheimer's 12.7% and epilepsy 9.3%. In the year 2020 unipolar depression will be the second cause of the ten leading causes of DALYs and among females it will be the first cause of disability in both developed and developing countries. (Lopez and Murray, 1996). In developed countries the cost of medication including the novel ones does not exceed l0-20% of the total cost of hospitalization. The reverse is true in developing countries where it is estimated to be 4050% as the cost of personnel and hospital care is low. (Okasha, 2000). And yet, the mental health budget remains the Cinderella of the total health budget. While the total health budget represents 7-14% from the gross national product in industrial countries, it ranges from 1-5% in the developing ones. The World Bank estimates that 80% of the total health budget in the world is spent on 10% of the population and 20% of the total health budget in the world is spent on 90% of the population with a health budget for individual USD 3500 in USA to one dollar in some countries. MENTAL HEALTH ACT Although Egypt has had a mental health act since 1944, many other Arab countries do not have such an Act. In Jordan two provisions in the Jordanian legislative system deal with the insane. In Lebanon, Bahrain and Tunisia the mental health act is part of the global

health legislation. In Bahrain a draft mental act is being worked out. In Palestine there is none and in Morocco a draft is being prepared. In the emirates the reference is to a ministerial decree which is less powerful than legislation and in Saudi Arabia the current relationship between doctors and patients is organized according to Shari'a (Islamic jurisprudence). A project is underway to regulate the practice of the profession and is derived from the Islamic Shari'a. In Libya there is none, although the national committee for mental health is preparing a workshop to discuss the need for one. Until then the principles of general law are applied to psychiatric patients. In Yemen there is no such act. Most of the existing laws dealing with mental health are old and were written prior to the new testaments and concepts of community psychiatry and integration of mental health into general health systems (Okasha and Karam, 1998). The need for a mental health legislation is mandatory to define the responsibilities and extent of authority of professionals and institutions and to prevent the abuse of mentally ill patients by families, society and professionals. Mental health acts should define the minimum responsibilities of the government, the privileges, responsibilities and liabilities of professionals, clarify the roles and limitations of caregivers, and establish criteria and rules for the rights of the patients and ways to protect them. The scope of legislation should involve the patient's right to treatment, patient's individual human rights, rights and obligations of the family, the community and the legal basis for service development, etc. Patient and family and the wider community need support in facing the consequences of mental illness. Mental health legislation provides guidelines for medico-legal purposes (i.e., criminal responsibility, financial affairs), to safeguard the provision of better and more affordable and more accessible services; to provide legal support to the activities in areas related to promotion of mental health and prevention of mental illness and to define the minimum responsibilities of the governments in these areas; to provide guidelines for using different treatment modalities in order to prevent any abuse. In order to understand the meaning of insanity in Islamic law, it is important to understand the concept of mental competence and legal capacity of a free Muslim citizen. Competence (ahlia) in Islamic law includes entitlement to rights and duties by virtue of being a human, a state referred to as themma. For example, the fetus while inside the mother's womb is entitled to receive an inheritance, carry the father's name, be the subject of a will, receive appropriate medical care, and so on. Competence of entitlement also obliges the individual to fulfill certain duties regardless of his or her comprehension of these duties. For example, a person of any age or mental function is obliged to pay blood money for a relative who has committed homicide or manslaughter (Chaleby 2001). In addition to competence of entitlement, there is also competence of performance which involves the legal capacity to carry out certain activities or to perform a certain task. It is stated in Islamic law that everybody who reaches the age of maturity is mentally competent unless he or she is declared otherwise. The mentally competent possess reason ('agil), are fully responsible (mukallaf) and capable of deliberate intent ('amad) (Scachit 1964). The majn'an lacks reason ('adim al-'aqil) and deliberate intent and is therefore liable to interdiction or legal incompetence.(Chaleby 2001)

MENTAL HEALTH POLICY Out of nine Arab countries who have responded to our inquiry, only 5 have a documented mental health policy (Egypt, Bahrain, Yemen, UAE and Morocco). In Yemen there is a mental health program of the Ministry of Health that is sponsored by WHO; it mainly targets the integration of mental health service into primary health care. In addition there is a five year plan of mental health services that is incorporated into the 5-year plan of the ministry of health. In Palestine, Libya and Tunisia, the mental health policy is part of the general health policy and in Jordan a draft was prepared in 1986 and has not been implemented yet, so practically there is no mental health policy (Okasha and Karam, 1998). In the absence of such policies, strategizing for the promotion of mental health is not feasible. This outline of the present status of mental health services in the Arab countries clearly recommends a future strategy for raising the quality of service. This strategy should specifically target: 1. Development of mental health resources, especially human resources 2. Incorporating mental health basic sciences in the curricula of medical schools targeting the graduation of general practitioners with adequate orientation to mental health problems and their management. 3. Development of mental health policies and mental health acts in Arab countries, which have not yet accomplished those missions. The possibility of a unified mental health act will be discussed. If we can have a small effect on the mental health of the 230 patients per 1000 population presenting each year to primary care, it will have a much greater effect than the continued assault on the 5.7 psychiatric inpatients per 1000. In planning for mental health we should be guided by the general principles that should guide a formulation of a mental health policy. Such policy should be based on decentralization of service, an integration of mental health policy into the general health policy, comprehensiveness of the policy outcome and equity. People should have equal access to the health care, which dictates an equitable distribution of resources and, maybe, a legislative matrix that promotes the social values and protection of mental patients. Such policies should be sustainable. The main element in securing sustainability is the participation of the stockholders in its formulation. Community and civil society participation in the formulation of their health policies in germinal and the mental health policy in particular is mandatory to the credibility of such policy and its support by its target beneficiaries: our patients, their families and the communities in which they live. A mental health policy should target the prevention and treatment of mental disorders and their associated disabilities, ensuring availability of minimal mental health care to vulnerable and underprivileged, the use of mental health knowledge to improve general health care and the application of mental health principles to improve quality of life (Okasha and Karam, 1998). To implement those objectives we should raise the awareness of the population regarding

mental health and mental health problems, have a comprehensive data base of mental health morbidity, have a planned budget, train and update available human resources and maybe generate new resources and redistribute our bed strengths. Because of the very tight budgets and limited resources available at this time and as a transitional period, the best plan for developing countries, our region being no exception, is to train and update GPs to look after the chronically ill patient and the families. This will give a better and lasting support and care than in hostels or day hospitals. We have abundant GPs as compared to psychiatrists and as previously mentioned the more orientation of GPs to mental health end the preference of patients and their families to attend the GP and the natural course of the referral system and the family role of support can give a better service for mental patients in developing countries than the present system of community care in industrialized ones.
Table 1 Present Use of Narcotics in Regional States Country Egypt Bahrain Tunisia Libya Lebanon Country Egypt Bahrain Tunisia Libya Lebanon Substance Her-hash-Drugs Op-Her Narc-Hash Hash-Her Hash-Narc Substance Khat Khat Hash-BZ Her-Op-Drugs Number Not available 1,806 Infrequent Infrequent Not available Number Frequent Frequent Frequent Infrequent Country Gipotti Yemen Sudan Oman

Source: World Health Organization, 1993.Op: opiates; Her: heroin; Khat: a stimulant plant chewed by people mainly in Yemen and Somalia; Narc: narcotics; Hash: hashish; BZ: benzodiazepines Table 2 Psychiatric beds and mental hospitals in some Arab countries (Mail survey) Country Egypt Bahrain Palestine Saudi Arabia Lebanon Beds 9000 201 352 2000 1800 Hospitals 9 state, 9 private 1 2 6 3 Country UAE Jordan Yemen Libya Beds 30 560 170 in gen. hosp 400 in prisons 1550

2 acute units Count Egypt Bahrain Palestine Saudi Arabia Lebanon Table 3 Medical personnel in relation to population (Mail survey) Country Bahrain UAE Qatar Kuwait Libya Tunisia Saudi Syria Jordan Country Bahrain UAE Qatar Kuwait Libya Tunisia Saudi Syria Jordan Table 4 Mental health professionals in some Arab countries (Mail survey) Country Lebanon Jordan Egypt Bahrain Palestine Psychiatrists 60 60 including those under training 1000 25 10 trained, 11 under training psych/pop 1 / 45000 1 / 60,000 1 / 66,000 1 / 223,900 Psychologists 19 30 211 3 6 pop/docor 775 1042 530 690 962 1852 704 1220 649 pop/doc 1064 1100 413 1667 770 4348 pop/nurse 568 328 407 310 1031 641 pop/nurse doc:nurse 1:1.8 1:2.9 4.5 2.2 1.1 1.01 Doc Country Algeria Oman Lebanon Iraq Egypt Morocco Yemen Sudan Hospitals 1 2 general 1 military none 2 Univ. hosp.

2174 1370 1818

0.18 1.2 2.3

Yemen UAE Tunisia Saudi Arabia Morocco Country Lebanon Jordan Egypt Bahrain Palestine Yemen UAE Tunisia Saudi Arabia Morocco Table 5

25 40 100 181 140 Social workers 38 100 300 6 13 30 473 4

1 1 1 1

/ / / /

500,000 62,500 84,000 88,950

13 All together 300 104 45

1 / 187,142 Psychiatric nurses 187 100 1355 67 5 109 1239 250

Health expenditure in comparison to military expenditure in some Arab countries (WHO 2001) Country Public expenditure on health as % of GDP 11.3 8.8 5.3 5 4.6 4.4 4.3 4.0 4.0 Country Public expenditure on health as % of GDP

Lebanon Jordan Tunisia Bahrain Morocco Sudan Egypt Qatar Saudi Arabia

Syria Algeria Iraq UAE Libya Kuwait Oman Yemen

4.0 4.0 4.2 3.7 3.7 3.3 3.2 2.9

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