Mental Health Policy in Malaysia: A Review and Recommendations

In September 2015, the topic of mental health was included in the UN Sustainable Development Goals (SDGs). In this historic step, the United Nations (UN) acknowledged the burden of disease of mental illness and defined mental health as a priority for global development for the next 15 years. Mental health is a current issue that becomes a problem among developing country. In Malaysia, the National Mental Health Policy have been enacted as one of the measures to address the growing mental health problems. This article aims to give a review and recommendations on Malaysian National Mental Health Policy based on previous research. This review involves nine principles in the Malaysian National Mental Health Policy including accessibility and equity, comprehensiveness, continuity and integration, multi sectoral collaboration, community participation, human resource and training, standards and monitoring, research, and legislation. The library research method has been applied in this study and several recommendations on the Malaysian National Mental Health Policy have been listed. Based on the findings, there are several recommendations on the Malaysian National Mental Health Policy that can be proposed to achieve the objectives of the mental health policy, which aims to improve the mental health and well-being of Malaysian citizens.


Introduction
Mental health is defined by the World Health Organization as a state of well-being in which an individual is aware of self-efficacy, can handle stress effectively, perform work productively, and able to contribute to society (World Health Organization, 2004).In every phase of human life, starting from childhood to adulthood, mental health is an important aspect that needs constant attention.This is because mental health is fundamental to the well -being of individuals and the ability of society to function effectively.
Individuals with mental health problems are unable to think rationally and are at risk of acting out of control.The American Psychiatric Association has identified 20 types of mental Vol 14, Issue 1, (2024) E-ISSN: 2222-6990 health problems faced by the world community.The death rate caused by mental health problems has also been alarming.Based on earlier studies conducted, it was found that the death rate due to mental health problems increased from 28.1 million deaths in 1990 to 49.7 million deaths in 2020, resulting in an increase of 77 per cent.Based on the seriousness of the impact of mental health on people worldwide, the United Nations (UN) has listed mental health in the Sustainable Development Goals (SDGs) (United Nations, 2015).This move shows that the UN recognizes the weight of mental health issues, thus making mental health a priority in the global development for the next 15 years.
In 2020, mental health issues or problems which are regarded as non-communicable diseases should be given priority because seven out of ten deaths are due to noncommunicable diseases.Mental health issue like depression is ranked third out of the top ten causes of disability among individuals worldwide.For example, in the Southeast Asian region, in which the population accounts for one quarter of the world's total population, mental health problems are a major burden faced by most countries in this region.Based on a study, the prevalence rate of mental disorders is high among the population of the Southeast Asian region with a rate of 27 per cent compared to other regions, such as Africa (nine per cent), Eastern Mediterranean (16 per cent), Europe (12 per cent), America (15 per cent), and Western Pacific (21 per cent) (World Health Organization, 2017).Mental health experts have predicted that by 2030, mental health problem like depression will inevitably rank second in the list of disease burdens that middle-income countries face.
Recently, mental health issues have received great alarms from the community as well as the government.This is because of mental health disorders that continue to increase and affect people worldwide.The causes of this are ignorance of patients, family members, and society.Ignorance can be a bliss, but in the context of mental health issues, it may result in improper treatment that heightens a patient's uncontrollable stress, high anxiety, out-ofcontrol thinking, negative feelings, unhealthy lifestyle, and excessive jealousy.All these would lead to more serious psychological and social issues.800,000 deaths due to suicide were reported worldwide in 2016, in which 75 per cent involved men compared to women who committed suicide, whereby such cases involved both adolescents and adults, regardless of age (World Health Statistics, 2018).
To address this growing mental health problems, it is essential for the authority to implement effective mental health policies.A mental health policy is an organized set of values, principles, and objectives to enhance mental health and reduce burdens of mental disorders among a population (World Health Organization, 2004).Sound and comprehensive mental health policies can increase the significance of mental health to be as important as physical health, help address issues of stigmatization of mental health in society, be the main pillar for the development of mental health programs, and play an essential role in delivering mental health services in an integrated manner.
In this study, a review of the Malaysian National Health Policy based on previous research will be presented.The highlight of the discussions will be based on the eight principles contained in this policy including accessibility and equity, comprehensiveness, continuity and integration, multi sectoral collaboration, community participation, human resource and training, research, and legislation, which is then followed by the recommendations towards this policy.

Literature Review
In line with Malaysia's mental health vision to create a psychologically balanced and healthy society, with emphasis on the promotion of mental health and the prevention of psychosocial problems, the National Mental Health Policy was formulated by the Ministry Health Malaysia in 1998.This policy, which was later revised in 2012, contains three important objectives, namely (i) to provide a foundation in the formation of strategies and a direction for all those involved in planning and implementation of health programs aimed at improving the mental health and well-being of all citizens, (ii) to improve mental health services among the population who are at risk of having psychosocial problems, and (iii) to improve psychiatric services for those with mental disorders by providing the care and protection among families, communities, and relevant bodies.
The National Mental Health Policy emphasizes several important principles which are (i) accessible and equitable -this is to ensure that mental health care is accessible equally and fairly for every segment of society in terms of geography and economic capacity; (ii) comprehensiveness -to ensure complete and comprehensive mental health care and services covering promotional, prevention, treatment, and rehabilitation activities; (iii) continuity and integration -this aspect ensures that the mental health services are provided at the primary health care level and mental health programs and activities are integrated into programs that are provided through the primary health care system; (iv)multi-sector collaboration -this ensures that the Ministry of Health plays a key role in facilitating collaboration among various sectors through various mental health programs and activities required by them and enabling them to engage in a more meaningful society; (v) community participation -this gets the community to be involved in the planning, management, and evaluation of community-based activities to determine the rights, pride, and acceptance of these activities; (vi) human resources and training -this focuses on the planning and development of human resources in mental health should meet the needs of the country and this is a major investment in the health sector; (vii) standards and monitoring -this required mental health services to be provided at high quality standards of care with internal quality assurance programs available.It also complies with the standards contained in the United Nations resolutions related to the Protection of the Rights of persons suffering from mental illness; which is followed by (viii) research and development that should always be present to be implemented and funded by the public and private sectors; and (ix) legislation, where the rights and freedoms of people with mental health problems and mental disorders are guaranteed and protected through legislation.
Mental health policy should be the main guide in addressing issues related to mental health and is used as a measure to address the increasing number of mental health problems in Malaysia.However, the policy often receives criticism from various quarters.Former Deputy Prime Minister of Malaysia, Datuk Seri Dr. Wan Azizah Wan Ismail suggested that mental health policy in Malaysia be reviewed due to the increasing mental health problems in the country (Abas and Sukaimi, 2018;Azmi et al., 2021).Malaysia is at risk of having more people with mental health problems because the rate of experiencing such problems increases every year.Based on the National Health and Morbidity Survey (NHMS) conducted in 2015, the existence of mental health problems among the community in Malaysia in 1996 was 10.7 per cent and this has increased to 29.2 per cent in 2015 (Ministry of Health Malaysia, 2015).In 2017, the National Health and Morbidity Survey (NHMS) found that every one in five Malaysians suffered from mental health problems like depression, every two out of five Malaysians suffered from anxiety, while one in ten suffered from stress (Ministry of Health Malaysia, 2018).
The National Health and Morbidity Survey (NHMS) 2019 showed that the total number of Malaysians who suffered from depression was 2.3 per cent or half a million people (Ministry of Health Malaysia, 2020).The highest occurrence was in the Federal Territory of Putrajaya, which was 5.4 per cent, followed by Negeri Sembilan at five per cent, Perlis at 4.3 per cent, Sabah at 4 per cent, and Melaka at 3.8 per cent.The group that recorded the highest rate of depression was the B40 group at 2.7 per cent, followed by the M40 group at 1.7 per cent, and then the T20 group at 0.5 per cent.The situation has worsened when Malaysia was affected by the COVID-19 pandemic, which later caused the government to announce and implement a movement control order (MCO) that commenced on March 18, 2020.The growing problem of depression and anxiety in Malaysia leads to more detrimental effects among the society.Among the effects include suicide, which is on the rise.Based on the Royal Malaysia Police (PDRM) Statistics of 2020, a total of 638 suicide cases were reported in the country between January and July.When this number is compared to the number of suicide cases between January to July in 2019, it shows an increase of 143 per cent.
Malaysia is in a state that the mental health problems among their people are alarming.If there are no effective measures taken to overcome this condition, the nation will suffer even more in the coming years.It is detrimental to let the number of mental health cases to soar every year.Therefore, to overcome this issue, the National Mental Health Policy 2012 needs to be revised as proposed by the former Deputy Prime Minister.The analysis and evaluation of the policy needs to be based on the current needs and conditions of the society.

Methodology
This study used a library research method, which reviews on previous relevant literatures have been made including articles, books, and policy documents.According to George (2008), library research is not a mystery or a lucky dodge, but an investigation one controls from start to finish, even though the person in question cannot often tell which sources he or she will eventually discover.The data has been collected based on previous research and several themes have been identified.However, only the main themes are being analyzed and discussed in this study.The main themes that are being analyzed and discussed in this study are based on the main principles that are stated in National Mental Health Policy.

Results
There are 9 principles in this policy that will be reviewed

(i) Accessibility and Equity
The supply and distribution of mental health workers in government health care, especially psychiatrists and clinical psychologists, is problematic because their distribution is uneven and heavily skewed towards urban centers.The shortage of clinical psychologist is critical and affects the accessibility to mental health service in public healthcare in certain states and rural areas.The shortage of clinical psychologist also results in a compromise service standard, with issues ranging from long waiting periods to make an appointment to limited consultation hours with mental health specialists (Siu Lin, 2018).Other than that, persons with disabilities (OKU) are also one of many parties that have issues when encountering the terms of accessibility of mental health service.This is because welfare aid and OKU status applications for the mentally ill can only be made through the Department of Social Welfare offices.Applications should be made more accessible if they could also be made in places that applicants often access, such as hospitals.Every public hospital in Malaysia contains a Medical Social Work Department that provides social services related to treatment (e.g.financial subsidies for hospital rates) and run by the Department of Social Welfare.However, they do not allow for welfare aid and OKU status applications (Galen Centre, 2019).

(ii) Comprehensiveness
Based on previous studies, mental health services in Malaysia are still incomplete and comprehensive as the number of psychiatric beds to population ratio is 2.7 units per 10,000 populations, which is low compared to the ratio in other countries (Toh et al., 2011).Previous study also found that some smaller district hospitals were less comprehensive, especially in terms of psychiatric manpower and facilities.Besides providing clinical service in their own hospitals, resident psychiatrists also paid regular visits to the smaller district hospitals to provide such service (Su Lin, 2018).Insufficient financial resources for mental health among low-and middle-income countries, including Malaysia, have been highlighted as one of a barrier to achieve comprehensiveness in mental health services.WHO's Mental Health Atlas 2017 found that median governmental expenditure on mental health in high-income countries was USD 80.24 per capita, while upper-middle countries (like Malaysia) only spent USD2.62 per capita.In 2019, the psychiatry and mental health department in the Ministry of Health Malaysia was allocated RM335 million, comprising 1.2 per cent of the total health budget, and a reduction of RM7.9 million compared to 2018 (Galen Centre, 2019).Allocations to services and supplies suffered a 14 per cent reduction, whereby such an occurrence would result in negative impacts arising on the comprehensiveness level of mental health services in Malaysia.

(iii) Countinuity and Integration
Nowadays mental healthcare has been integrated with the public primary healthcare and recent public primary healthcare clinics have expanded their services to include mental health promotion, early detection and treatment, follow-ups on stable psychiatric patients, psychosocial rehabilitation, and family interventions.This integration, however, could be an issue, as the primary healthcare sector has been operating beyond its limits.The average ratio of physicians to population in the Malaysian public healthcare sector is 0.9 per 10,000 populations, in contrast to the standard physician to patient ratio.A primary care physician sees an average of 40 patients daily, limiting their consultations to a maximum of 15 minutes per patient, which is almost twice the recommended standard workload, barely enough for a holistic consultation.This situation affects the continuity and integration principle emphasized in this policy.

(iv) Multi-sectoral Collaboration
Multi-sector cooperation in the field of mental health in Malaysia needs to be actively carried out as there is a need to establish a national planning team led by psychiatrists and composed of all stakeholders as committee members (Midin et al., 2018).This formation of a team is very important to be established to review and update policies and frameworks in the field of mental health and to fruitfully discuss matters related to mental health.Nowadays, mental health is tackled by multiple ministries due to its holistic nature.However, most services and programs often run without coordination and communication across ministries, or without consultations with professionals, patient advocates, and grassroots.The lack of consultation and coordination results in policies, frameworks, and plans that are less holistic, not well targeted, and are ineffective in tackling issues, such as prevention, promotion, access, and coverage (Galen Centre, 2019).

(v) Community Participation
Community also included the representatives of mentally disabled people and their families.According to the policy, community should be closely participated in the identification and implementation of community-based activities.As such, some of the families now participate actively on this and started to be involved in taking care of the mentally ill patients.They also participated in using community mental health services that are provided by the government.However, they tend to encounter problems, such as lack of attention from the mental health professionals at the community mental health service center, accessibility to the community mental health service center, and quality of the mental health services that are provided by the community mental health service center (Mohamad & Chong et al., 2011).This causes limited participation among the community.

(vi) Human Resources
The problem of lack of human resources, especially psychiatrists, has often received attention.Based on a survey on the number of psychiatrists conducted in 2018, there is a large gap between the number of psychiatrists and their distribution rate throughout Malaysia.There are 410 registered psychiatrists in Malaysia with a ratio of 1.27 psychiatrists per 100,000 populations.Other than psychiatrist, Malaysia also has a lower number of clinical psychologists.Clinical psychologists made up the lowest proportion of all categories of government-based mental health providers, making up 0.04 per cent of the entire workforce, or 12 of out of 2780 workers.Furthermore, when compared to other groups of mental health providers, clinical psychologists were found to be at abnormally low levels.In 2016, only 12 clinical psychologists were working in government healthcare facilities, compared to 163 psychiatrists, 188 counsellors, and 146 occupational therapists.The approximate ratio of clinical psychologists to psychiatrists was 1:14 (Su Lin, 2018).

(vii) Standards and Monitoring
It is the right of every mental health consumer to be provided with quality care, and quality will be a major requirement of an acceptable health care system.It must include the availability of qualified or trained personnel who provide mental health care which meets the standards of technical competence, efficiency, and effectiveness.However, in rural areas, such as Kedah and Sabah, the availability ratio of qualified psychiatrists is 0.54 -0.55 psychiatrists per 100,000 populations in the states.This is still far behind the standard ratio that has been designated by the World Health Organization as 1 psychiatrist per 10,000 populations (Midin, M. et al., 2018).This situation affects the standards and monitoring, especially in terms of mental health services provided for the community.

(viii) Research
It is important to conduct current research related to mental health issue and mental health problems to get the latest findings.Findings from the research are crucial and fundamental to assist the authorities in solving any issues related to mental health.Data from the findings are also important for the researcher to conduct new research on mental health.However, the collection of current data collected by multiple agencies is often fragmented, and data that exists are not streamlined, aggregated, collated, and are often inaccessible to the public.This makes research related to mental health difficult to conduct.An attempt to collect systematic mental health-related data was done via the National Mental Health Registry (NMHR).It was, however, discontinued after 2007 due to administrative constraints, with existing data reportedly containing gross under-reporting and reporting biases because most of the registered cases were of schizophrenia.

(ix) Legislation
National Mental Health Policy states about legislation to ensure the rights and freedoms of people with mental health problems and mental disorders are guaranteed and protected through legislation.However, Section 309 of the Penal Code criminalizes any person who attempts suicide with imprisonment of up to one year, with a fine or both.This legislation has had negative consequences for those who suffer from mental health problems and attempt suicide (Galen Centre, 2019).

Discussion and Recommendation
To achieve the objectives of the mental health policy of improving the mental health and wellbeing of all citizens, all matters that are deemed to be important should not be overlooked.These improvements can be made by filling in the gaps or rectifying the weaknesses in this policy.First, the government needs to solve the shortage of workforce in the mental health field because this problem affects the accessibility, comprehensiveness, and human resources principles that were emphasized in this policy.As stated, Malaysia lacks psychiatrists and clinical psychologist.
The relatively low numbers of psychiatrists may be linked to a negative stigma towards mental illness among the medical profession, and consequently, low interest among medical graduates to pursue psychiatry as a career.To solve this problem, government through the universities should give medical students exposure to clinical settings to give them exposures to a certain extent in terms of the experiences of working as a psychiatrist and thus dispel some of their doubts or negative stigma about the profession.The Ministry of Higher Education (MOHE), for example, should consider revising the content of the undergraduate medical course syllabus to include greater psychiatric education, to give medical students more exposure to discussions of mental disorders while still in medical school.
For the clinical psychologist, a potential key factor driving the critical lack of clinical psychologists in government services may be that there are not enough positions for clinical psychologists in government hospitals.The Ministry of Health (MOH) creates very limited positions for these mental health professionals because the roles of clinical psychologists were quite often confused with counseling psychologists.To solve this, the MOH should restructure their hiring system and create separate recruitment pathways for clinical psychologists.The MOH also should set up separate clinical psychology departments in all government hospitals to show that this position has their own role in mental health service.
Although this policy emphasized multi-sectoral collaboration in the mental health field, but most of the services and programs often run without coordination and communication across ministries, or without consultations with professionals.And so, it is suggested to establish a multi-sectoral committee with representatives from different ministries and stakeholders, chaired by the Ministry of Health.This initiative can help to coordinate all the services and programs that are related to mental health so that the services and programs will become more holistic, well targeted, and effective in tackling issues, such as prevention, promotion, access, and coverage.
Improvements can also be made in terms of research and legislation because these two principles are important in this policy.For the research, the government needs to improve their data collection related to mental health.Data collection should be done with the involvement of multiple ministries, with the Ministry of Health in charge of coordinating and collating data.As a start, the registry could compile existing data related to mental health from other registries, as per the National Mental Health Performance Report 2016.This initiative is very beneficial to the researchers who are interested in conducting more research related to mental health.
As for the legislation, criminalizing suicide as a form of deterrent does not give a positive effect to those who are facing mental health problems.It is suggested to repeal Section 309 of the Panel Code.This is because criminalization is identified by the World Health Organization (WHO) to deter access to treatment, stigmatizes the act of suicide, worsens the mental health of those put through the criminal justice system, and discourages people from coming forward for treatment due to fear of prosecution.Criminalizing suicide as a form of deterrent has also proven to be a matter of the increasing suicide rates in certain countries, like Hong Kong and England.

Conclusion
If the government is serious about improving the wellbeing of people and overcome the growing mental health problems among Malaysians, they must ensure to develop the policies and interventions based on an in-depth understanding and for that The National Mental Health Policy needs to be revised as proposed by the former Deputy Prime Minister.The analysis and evaluation of the policy needs to be based on the systematic evidence (evidencebased policy) and meet the current needs of the society.Conducting extensive national research and development programs in the field of mental health would certainly contribute to the service providers in improving the service to better meet the needs and requirements of the whole population.The research output could also be used to develop the evidence-based policy.It is agreed that policy, which is based on systematic evidence, is seen to produce better outcomes.