- Email: [email protected]
The modern mental health system in Nepal: Organizational persistence in the absence of legitimating myths
Pergamon PII: S0277-9536(96)00364-4
Soc. Sci. Med. Vol. 45, No. 3, pp. 441-447, 1997 © 1997 Elsevier Science Ltd All rights reserved. Printed in Great Britain 0277-9536/97 $17.00 + 0.00
THE M O D E R N MENTAL HEALTH SYSTEM IN NEPAL: ORGANIZATIONAL PERSISTENCE IN THE ABSENCE OF LEGITIMATING MYTHS MARK TAUSIG'* and SREE SUBEDI 2 'University of Akron, Akron, OH 44325-1905, U.S.A. and -'MiamiUniversity, Oxford, OH, U.S.A. Abstract--This paper advances an organizational explanation for the slow pace of modernization of mental health care systems in developing societies. In complement to cultural and political economic explanations of this condition, we suggest that the value of establishing modern systems in developing societies lies in the legitimation such structures provide for indigenous modernizing efforts vis-d-vis both indigenous and external audiences. The system need not meet actual levels of service demand. Its importance is in its symbolic value as an indicator of modernity. The result is a system in "permanent failure". Implications for institutional theory and the growth of modern mental health systems in developing societies are discussed. © 1997 Elsevier Science Ltd Key words--mental health, developing societies, institutional theory
INTRODUCTION
The creation of modern systems of mental health care in developing countries is becoming a matter of great concern and interest. It is estimated that mental health problems directly account for 8.1% of lost years of quality of life and are indirectly associated with another 34% of disability conditions (Desjarlais et al., 1995). Despite commitments from a large variety of funding sources in the developed world, modern mental health systems in developing societies are poorly established and have grown slowly. The question is, "what explains the slow process of establishing modern health care systems in developing societies?" In this paper we will explore the utility of an answer based on a social institutional explanation. We argue that existing cultural and political economic explanations, while necessary, are not sufficient to account for the observed state of development of modern health systems. Indeed, while such explanations address barriers to development and the functional "failures" of modern systems, we will also suggest that failed systems may represent successful symbolic institutional exemplars of modernization. In this respect, the slow development of a modern system of health care masks the successful symbolic value of adopting a modern form of social organization. We wilt discuss the modern mental health care system of Nepal as an example of an organizational form that exists in a state of "permanent failure" yet which provides legitimation to modernizing efforts in that country. We will show that the pre*Author for correspondence.
441
sence of a modern mental health system per se, regardless of its actual size or corresponding relationship to need, legitimates the general societal enterprise of modernization. In doing so we observe an interesting reversal of a causal sequence specified in institutional theory (Meyer and Rowan, 1977) in which new organizations derive legitimacy from adopting structural forms that are isomorphic with prevailing forms (i.e. bureaucratic, rational). In the case at hand, the sequence is more complex and nonrecursive. The modern organizational form legitimates a new cultural myth in the developing society as well as legitimating the efforts of the society in the eyes of external (modern) social systems. The institutional perspective can, therefore, be used to explain the weak development of modern organizational forms in developing societies a n d their persistence despite this weakness.
BACKGROUND
Improvement of the health status of the general population is a central goal in virtually all developing nations of the world (WHO, 1978). To this end most of these countries have borrowed and adapted Western medical techniques and technology to some degree. Generally, modern health systems are employed as a means for reducing infant mortality, improving basic sanitation practices and reducing the incidence and prevalence of infectious disorders. At the same time, the goal of health for all by 2000 is clearly not likely to be reached. Several general reasons have been proposed to explain this expected outcome. First, there is the issue of cultural contradictions. Discrepancies
442
Mark Tausig and Sree Subedi
between modern and indigenous understandings of health, illness and treatment are well-known (Kleinman, 1980). Indigenous explanations for the causes of sickness, the relationship between mind and body and the culturally appropriate forms of intervention can generate resistance to western forms of health care, reduce its use and undermine the continued growth of modern systems (Zeichner, 1988; Subedi, 1989; Gallagher, 1993). Modernization itself represents a set of cultural assumptions, values and beliefs as well as material changes and these may clash with indigenous assumptions, values and beliefs. Cultural resistance to either the specific explanations for illness or the implications of modernization in general can slow or stop the development of modern health systems. Political economic arguments are also well-established as explanations for underdevelopment. As a rule these arguments are based on the economic dependence of developing societies on developed societies in the world system (Navarro, 1986; Alubo, 1993; Reich, 1993; Desjarlais et al., 1995). One of the defining characteristics of developing societies is the absence of indigenous capital with which to modernize the existing social and economic infrastructure and to create the organizational resources necessary to establish an enterprise as sizable as a health care system. Typically, developing societies make use of loans and grants from developed countries to create these systems. World systems theorists argue that financial institutions such as the World Bank and International Monetary Fund (as well as governmental and private sources of "foreign aid") use their control of economic resources to maintain a domination-subordination relationship between donor and donee. They emphasize economic activity in developing countries that is considered valuable to economic interests in the developed world as opposed to the well-being of individuals in developing societies. In other words, health and health care systems in developing countries are not a high priority for funding agencies in developed countries. It is only recently that the World Bank has "discovered" the importance of health as a focus for investment (Hecht, 1995). Even then, funders prefer to channel their financial support through "financially responsible" conduits (Atkinson, 1995). Developing societies themselves also establish priorities for development (Desjarlais et al., 1995). This is done partly as a function of the scarcity of economic resources and partly as a function of internal political concerns. Thus, the creation of a comprehensive and ubiquitous health care system may have a lower priority compared with the development of the physical infrastructure or the creation of viable economic organizations. Third, the perceived importance of physical health as opposed to mental health as a priority in developing societies serves to restrain the growth of
mental health systems (Desjarlais et al., 1995). It is only in the last few years that the extent and severity of mental health problems in developing societies has begun to be systematically described and regarded as an important health problem (Harpham, 1994). This "bias" mirrors the relative neglect of mental health systems in developed societies. It is also related to modern funders' standards for assessing health status in developing societies in terms of infant mortality, control of infectious disorders and population growth but not in terms of psychological well-being. Cultural incompatibility, the world and domestic political economies and internal developmental priorities are most useful for explaining the absence of modern systems. They do not do as well for explaining why a modern mental health system exists at all or why it might exist at a very low level of development. These questions require a fourth account centered on the symbolic importance of modern forms in developing societies. It is from such accounts that we will construct an institutional argument to systematize the relationships among all the proposed explanations for the underdevelopment of health systems. On one level the adoption of modern medical practices is based on its demonstrated effectiveness. The adoption of a modern medical philosophy, however, also includes the institutionalization of a form of organization that is based on an ideology of western bureaucratic rationality. Modern health systems are symbolic "carriers of modernity" (Phillips, 1990; Gallagher, 1993). In this sense, such systems legitimate the general process of modernization within the developing society. The material success of modern medical processes facilitates the symbolic acceptance of the underlying form of organization that supports this material success. Such legitimation has benefits for the state and is, therefore, supported by the state (Frank, 1988). Frank argues, for example, that modern medical systems legitimate the expansion of the state for other purposes, as well. Thus, the state and medical systems provide legitimation for one another. The legitimation of the enterprise of modern health services in developing countries like Nepal can initially only be established by reference to modern societies with a firmly based institutional ideology using rational principles. To some degree there will otherwise be cultural contradictions between existing forms of social organization and those based on bureaucratic principles. The advantage of using such an organizational principle in developing nations, however, lies not only in its internal social, economic, and political value as an indicator of the progressive modernization of the society but also in the legitimating function it plays in attracting funds and personnel from developed societies. Alubo (1993), for example explains that a developing country must satisfy the symbolic expec-
The modern mental health system in Nepal
443
In many developing societies modern and indigenous forms of organization coexist. This coexistence can be seen as a means for maintaining traditional cultural identities while simultaneously providing openings to modernity. In this regard the existence of modern organizational forms cannot be legitimated in terms of indigenous cultural systems but only with reference to modern systems. The presence of mimetic (imitative of modern forms) organizational systems also helps to legitimate the socioeconomic and political enterprise of modernization within developing countries by providing concrete examples of development for the indigenous population. The presence of these organizations fuels external investment in the developing country. The enterprise of modernization generates both socioeconomic and political capital in developing countries through the legitimation accorded to activities that mimic those of developed societies. The result points to the importance of socioeconomic and political factors for development, but in an unusual way. What is different about this analysis is the manner in which the existence of modern organizational forms are explained and their effects on the economic and political behavior of the state. Figure 1 shows that indigenous modern organizations derive their legitimacy from mimetic correspondence with modern organizational forms. This initial cognitive legitimacy can then be used to generate socioeconomic and political legitimacy for indigenous modernizing political elites who, in turn, gain cognitive and socioeconomic legitimacy from developed countries that can be converted into
tations of western financial interests in order to receive continued financing. Hecht (1995) and Atkinson (1995) make it clear that organizations such as the World Bank and Save the Children Fund make funding decisions based on perceptions of the legitimacy of efforts to establish modern systems. In turn, the ability of a developing society to satisfy external funders, enhances the internal political position of the State (Alubo, 1993).
AN INSTITUTIONALEXPLANATION These observations about the symbolic importance of modern organizational forms can be systematically integrated with the previous recognition of cultural and political economic barriers to modernization to obtain a more complete explanation for the fate of modern health care systems in developing societies. The institutional theory originally outlined by Meyer and Rowan (1977) and elaborated by them and others (Meyer and Scott, 1983), seeks to explain why organizations in modern society have such uniform surface structures despite wide variations in technical processes and objectives. It is argued that all organizations must obtain cultural legitimation for their activities by adopting the appearance of formal rationality, the institutional myth prevailing in the "modern" cultural environment. Demonstrating organizational conformity to this institutional myth confers legitimacy on the organization and improves its chances of survival and access to social resources.
Indigenous Societies Cognitive Legitimacy °ci°-P°liticalLe gitimacy
~
Indigenous Elite Stability (Sourcesof Rational-Legal Formsand Economic Resources)
Cognitive Legaimacy L
(CognitiveLegitimacy ~ acquit, by form) assoming
~ "~~Ind~gre
Socio-Economic Political Legitimacy
/ /
~ , ~ t M ~ ern
Fig. 1. A nonrecursive model of the relationship between legitimating sources and organizations in developing societies.
444
Mark Tausig and Sree Subedi
development projects which enhance indigenous legitimacy. Ordinarily in institutional analysis the adoption of rational ceremony by an organization serves to legitimate goals of the organization and its existence. For example, mental health services in modern societies are acceptable as an organizational activity partly because the activity is conducted within an acceptable organizational structure. However, in the case examined here it is clear that the adoption of a specific rational organizational myth and form does not lead to the extension of mental health services in any way that indicates organizational success. The reason for this is that the organizational enterprise itself and the actual delivery of specific organization outputs such as mental health services is of secondary importance to the symbolic legitimation of socioeconomic and political activities. In light of the previous discussion, it should now be clear that institutional theory can be used to integrate cultural and political economic arguments regarding modernization and barriers to modernization with observations about the symbolic meanings of modernization processes. It is time to turn to a case study of a modernizing society to examine how these processes work in an actual situation. THE M O D E R N MENTAL H E A L T H SYSTEM IN NEPAL
Nepal is a society undergoing a transition toward a "modern" social system. The development is, however, uneven. This is partially owing to the fact that Nepal remained relatively isolated until 1951 and exposure to western or modern ideas and ideals was limited (Subedi, 1989). Exposure is thus relatively recent and largely confined to the urban population of Kathmandu, although it has had some effect on other towns and rural areas owing to the influence of the mass media and the influx of tourists. In some places this has resulted in out-migration pressures and disruption of traditional village stability. In spite of this, traditional (Hindu) Nepali society is almost intact in the majority of the country. In the summer of 1994, extensive interviews were conducted with government officials, facility directors and facility staff in order to understand the organization and practice of modern mental health services in Nepal. Documents pertaining to planning, need and utilization were also obtained where possible. All interviewing was confined to Kathmandu which is the only location where modern mental health services are available within the country. Indigenous and modern mental health care systems coexist. Most of the indigenous mental health care is provided by folk practitioners known as Jhankries and Dhamis. According to Streefland (1985) (p. 1155), "the most widely prevailing medi-
cal system in Nepal is faith-healing", and it is strongly rooted in the minds of most people. In Nepali society, traditional cultural institutions continue to dominate the explanations of the causes and care of persons regarded as "mentally ill" by modern forms of assessment. Hence, faith healers such as Jhankries and Dhamis receive wide public acceptance and play a significant role in meeting the health care needs of the population (UN, 1980). For example, Achard (1983) reports that a patient in a hilly region of Nepal is more likely to contact a Jhankri/Dhami for a mental health problem than any other health services provider. In Nepali folk medicine symptoms of distress are both somatic and psychological and are explained as attacks or possession by demons, ghosts or spirits. The origins of these attacks or possession may be the random malevolence of ghosts etc. or may result from conflicts within the community which cause an aggrieved party to direct a demon to bring misery to a member of the responsible family. Regardless of the specific cause, a family may hire a Jhankri or Dhami to expunge the demon and cure the patient. It is generally the case that patients who utilize the modern forms of health treatment in Nepal have visited indigenous healers prior to seeking modern forms (Subedi, 1989, 1992; Subedi and Subedi, 1995). The modern trained psychiatrists in Kathmandu report no conflicts with folk healers and, indeed, have found them to be cooperative in that Jhankries/Dhamis sometimes refer patients to the modern mental health system. This suggests that cultural contradictions alone cannot explain the utilization and extent of modern mental health services. While modern forms of medical treatment remain foreign to most people, the extent to which cultural contradictions function as an actual barrier to utilization of modern health services is questionable. Moreover, patterns of utilization of existing modern health services suggest that they are mostly used by economic and political elites who are highly supportive of modern cultural values (Subedi and Subedi, 1995). The modern mental health system in Nepal began in 1962. At present, the complete modern mental health system (that is, agencies which use standard ICD/DSM diagnostic categories, standard psychopharmacology and employ trained psychiatrists) consists of one 40 bed acute care facility and its allied outpatient department. In addition, there are two 12 bed wards at the general hospital and the teaching hospital in Kathmandu. This latter facility is partially staffed by British psychiatrists and funded by the United Christian Mission. Further, there are four to five bed wards in the military hospital and two regional hospitals. A small community mental health program has also been established at three regional hospitals. Finally, there is a limited program (funded by the United Mission) to teach modern-trained health pro-
The modern mental health system in Nepal fessionals to screen for mental health problems. The acute care hospital was started in 1984 and the teaching hospital ward was established in 1987. There are a total of 13 trained psychiatrists in the country, all working in Kathmandu. The mental health care units outside Kathmandu are run exclusively by personnel and/or physicians who are not trained in psychiatry. No services exist for the chronically mentally ill. The acute care hospital admits patients in active psychotic states who appear to be in imminent danger to themselves or others. Often families bring patients from rural areas which may require several days' journey. Diagnosis is perfunctory and used as a general indicator for treatment course. The main objective is to restore some degree of "insight". Electroshock treatments are given to 20-30% of patients and the average length of stay is three to four weeks. The hospital admits 500-550 patients per year and there is a readmission rate of 70%. While treatment and medication are free in the hospital, the patient must pay for medicine after leaving the hospital. The outpatient department functions six days per week and treats approximately 8000 patients per year, most on a regular basis. Treatment is largely medication based. The psychiatric wards at the general hospital and the teaching hospital do complete diagnostic workups of their patients and provide treatment according to standard western protocols. Psychiatrists report high levels of conversion disorders and hysteria, reflecting the absence of a cultural distinction between mind and body. The teaching hospital also has an active program for training medical personnel to screen for psychiatric disorders. They have developed a short screening form for identifying epilepsy (recognized as a mental disorder in Nepal), depressive disorders, psychoses and antisocial personality disorders. Identified cases are referred to the mental health unit of the teaching hospital. At the national planning level very few resources are devoted to mental health. Government priorities are clearly directed toward health programs to reduce infant mortality, infectious diseases and parasitic disorders (Subedi and Subedi, 1993). Nepal's infant mortality rate is among the highest in the world and life expectancy is among the shortest. Nepal receives substantial external funding for programs which address these problems. The health department has no epidemiological data regarding prevalence or incidence of mental disorder. The World Health Organization collaborated in a smallscale survey in 1987 and the findings from this survey are the sole scientific data available for planning. A separate line for mental health services in the national health budget was only established in 1984. This money supports the psychiatric ward at the general hospital, the acute care hospital and the training of two psychiatrists per year in India.
445
There is only a vague recognition at the governmental level of the extent and impact of mental health problems. Despite this, however, the state officially endorses the development of a modern mental health system and regards its efforts as part of societal modernization efforts. To summarize, a modern mental health system has been established in Nepal but it is clearly inadequate to meet the mental health needs of the population, which have also not been clearly identified. Its growth has been stagnant. It persists, but does not thrive or develop. Evidence suggests that, despite culturally different views of mental illness, indigenous and modern systems of mental health services are not in conflict with each other. Owing to the absence of conceptual antagonism, cultural resistance cannot fully explain the failed state of development of the modern mental health system. The mental health system is also seriously underfunded and this is clearly a function of externally driven (western funding sources) health status goals as well as objective conditions. Progress in reduction of infant mortality, decreases in rates of infectious and parasitic disorders, contraception programs, etc. are clearly regarded as markers of modernity and development by the Nepali government as well as more developed societies. The bulk of modern health care funding is directed toward these objectives. At the same time mental health services are regarded generically as part of a modern health care system and there are some external funds available for mental health services. The modern health care system in Nepal cannot be regarded as fully developed so that one can argue that it also suffers from organizational failure along lines very similar to those we have identified for mental health services. The overall poverty of the society cannot be entirely dismissed as an explanation for the under-development of modern social institutions. This account of the modern mental health system in Nepal makes it clear that issues related to cultural contradiction and/or political economy cannot alone explain the organizational status of the mental health system. In Nepal the modern mental health system exists in a cultural environment that values the symbolism of modern rational forms but does not value the organizational goal. In other words, the purpose of the organization is legitimated by reasons external to the indigenous institutional ideology and the organization's officially stated goals. More specifically, we suggest that the establishment of a modern form of a mental health system may serve the need for indigenous political economic elites to demonstrate their modernity to the developed world in order to obtain external legitimacy. This, in turn, will attract foreign investment and aid the social, economic, and political institutions of the society to align with a modernizing ethos. It is clearly possible for societies to import
446
Mark Tausig and Sree Subedi
the structural trappings of modernity (mimetic isomorphism of a modern mental health system) without the cultural underpinnings that are thought to give rise to the form. Such forms receive legitimation simply because they represent "modernity" and adoption permits the society to measure its level of modernity. The status of western-oriented "modern" mental health systems in many developing countries is markedly under-developed despite recognition of the high prevalence of mental illness (WHO, 1984). Institutional theory suggests that the success of organizations is partially a function of the isomorphism of their organizing rationale with legitimating myths about what constitutes proper form. In developing societies, such as Nepal, however, indigenous organizing rationales are not consistent with the survival of modern organizational forms. Rather, institutional myths of developed societies are generally admired and the presence of exemplars of modern organizations have enormous symbolic value as indicators of modernization. This admiration is not sufficient to create a thriving modern system, however. All that is needed to acquire this symbolic value is a minimal modern mental health system, one that may be described as being in a state of permanent failure characterized by high persistence and low performance (Meyer and Zucker, 1989). IMPLICATIONS FOR INSTITUTIONAL THEORY
This institutional analysis shows the involvement of socioeconomic and political processes in development but puts the outcome of establishing modern organizational forms related to development in a different light. These forms become independent predictors of socioeconomic and political development rather than results of such development. This argument explains why the mental health system is so small and inadequate in Nepal despite the need for mental health services. The usual institutional analysis assumes a causal progression in which a newly founded organization engages in a strategy designed to earn cultural capital and thus, obtain legitimacy from the external environment (Aldrich and Fiol, 1994). From this perspective the weak, under-developed nature of the modern mental health system in Nepal appears as a struggle for legitimacy by a culturally alien form with very limited cognitive or sociopolitical legitimacy. This causal assumption suggests that, over time, the mental health system may enlarge and increase its effectiveness as a function of general development in Nepal along western/modern lines. The general absence of the rational-legal form in traditional Nepalese society calls the accuracy of this causal ordering into question in the present case. Meyer and Rowan (1977) argued specifically that the legitimating effects of adopting the prevail-
ing organizational myth only operate within modern institutional systems. In developing societies, rational forms (such as the modern mental health system) are established mimetically to generate socioeconomic and political legitimacy for indigenous modernizing elites. In turn, the mental health system is then granted cognitive legitimacy by these sociopolitical elites. The application of the institutional approach to the question of why modern mental health services exist in the form they do can, therefore, be used to extend institutional theory. The analysis suggests the socioeconomic and political importance of gaining cultural legitimation and capital through the use of rational myth and ceremony but not just for a specific organization. Cultural capital is an apt term for the fruits of this type of legitimation. By reversing the causal order and using rational form to explain economic and political resource conditions, we can see that institutional theory's reach can be extended to analyze issues of modernization. In Meyer and Rowan's (1977) original formulation of institutional theory, modernization is an assumed prerequisite for explaining institutional isomorphism. We can now see that this isomorphism has generative properties of its own. This paper offers additional openings for the application of institutional theory by suggesting ways in which it can be applied to understanding the modernization process itself as well as the consequences for organizational forms and the role that isomorphism plays in the survival of organizations. Specifically, we suggest that there can be a nonrecursive relationship between organizational form and legitimation such that the existence of the form can sometimes confer legitimacy on the organizing ideology. Institutional theorists and organization ecologists have not examined this possibility because it is implausible given their causal assumptions. The extension of the theory cannot be fully tested without more cases and the passage of time. We need to observe a concomitant growth of rational legal forms in general and in the mental health system and we need to see it under varying internal and external political economic conditions.
IMPLICATIONS FOR THE DEVELOPMENT OF MENTAL HEALTH SERVICES
The mental health status of populations in developing societies is largely unknown. The World Health Organization (WHO, 1984) estimates that 20% of those who seek general health services present with mainly psychosocial problems and mental health is part of the official WHO definition of health. The WHO cites unchecked urbanization, destruction of traditional family life, mass migration, violence, crime and economic hardship as common stressors in developing countries. T h e s e factors are linked to increased rates of drug and
The modern mental health system in Nepal alcohol abuse, as well. Despite this understanding, mental health services are clearly underdeveloped in most modernizing societies. This situation is clearly a function of the funding and value priority that physical health needs have for both developing and developed countries. Cultural explanations for mental disorder also affect the "fit" between modern therapeutic techniques and those of other societies. On the contrary, modern mental health systems do exist in most developing countries but are under-developed. In this paper we have argued that one reason for this situation is the legitimating function that a modern organizational form plays in modernizing social systems. To the extent that mental health systems serve a symbolic rather than a functional purpose, we should not expect development of the system to parallel general material development. The growth and development of modern mental health systems will, for the time being, continue to depend on their value as a source of cognitive, socioeconomic and political legitimacy within the country as well as their ability to draw resources into the country from external sources. Mental health systems will neither disappear nor expand to the level required to address actual levels of psychological disorder in the population. Acknowledgements--The authors would like to thank their informants in Nepal and Mr. Bimal Pandey for his assistance in collecting data for this study. The advice of reviewers from this journal has also significantly improved the work. REFERENCES
Achard, T. (1983) Primary Health Care & the Hil& of Nepal. His Majesty's Government (HMG/SATA): Integrated Hill Development Project (IHDP), Kathmandu, Nepal. Aldrich, H. E. and Fiol, C. M. (1994) Fools rush in? The institutional context of industry creation. Academy of Management Review 19, 645-670. Alubo, S. O. (1993) Implementing health for all in Nigeria: problems and constraints. In Health and Health Care in Developing Countries, eds P. Conrad and E. B. Gallagher, pp. 228-245. Temple University Press, Philadelphia. Atkinson, S. J. (1995) Non-governmental organizations at the interface between municipalities and communities. In Urban Health in Developing Countries: Progress and Prospects, eds T. Harpham and M. Tanner, pp. 182200. St Martin's Press, New York. Desjarlais, R., Eisenberg, L., Good, B. and Kleinman, A. (1995) Worm Mental Health: Problems and Priorities in Low-Income Countries. Oxford University Press, New York.
447
Frank, J. (1988) Medical modernization in Mexico: paradigrns, labor markets and the state. In Modern and Traditional Health Care in Developing Societies, ed. C. Zeichner. University Press of America, Lanham, MD. Gallagher, E. B. (1993) Modernization and medical care. In Health and Health Care in Developing Countries, eds P. Conrad and E. B. Gallagher, pp. 285-306. Temple University Press, Philadelphia. Harpham, T. (1994) Urbanization and mental health in developing countries: a research role for social scientists, public health professionals and social psychiatrists. Social Science & Medicine 39, 233-245. Hecht, R. (1995) Urban health--an emerging priority for the World Bank. In Urban Health in Developing Countries: Progress and Prospects, eds T. Harpham and M. Tanner, pp. 123-141. St. Martin's Press, New York. Kleinman, A. (1980) Patients and Healers in the Context of Culture: An Exploration of the Borderland Between Anthropology, Medicine and Psychiatry. University of California Press, Berkeley. Meyer, J. W. and Rowan, B. (1977) Institutionalized organizations: formal structure as myth and ceremony. American Journal of Sociology 83, 340-363. Meyer, J. W. and Scott, W. R. (1983) Organizational Environments." Ritual and Rationality. Sage, Beverly Hills, CA. Meyer, M. W. and L. G. Zucker. (1989) Permanently Failing Organizations. Sage, Newbury Park, CA. Navarro, V. (1986) Crisis, Health and Medicine. Tavistock, New York. Phillips, D. R. (1990) Health and Health Care in the Third WorM. Wiley, New York. Reich, M. R. (1993), The political economy of health transitions in the Third World. In Health and Social Change in International Perspective, eds L. C. Chen, A. Kleinman and N. C. Ware, pp. 411 451. Harvard University Press, Cambridge, MA. Streeftand, P. (1985) The frontier of modern western medicine in Nepal. Social Science & Medicine 20, 1151 1159. Subedi, J. (1989) Modern health services and health care behavior: a survey in Kathmandu, Nepal. Journal o! Health and Social Behavior 30, 412-420. Subedi, J. (1992) Primary health care and medical pluralism exemplified in Nepal: a proposal for maximizing health care benefit. Sociological Focus 25, 321-328. Subedi, J. and Subedi, S. (1993) The contribution of modern medicine in a traditional system: the case of Nepal. In Health and Health Care in Developing Countries, eds P. Conrad and E. B. Gallagher, pp. I10 121. Temple University Press, Philadelphia. Subedi, S. and Subedi, J. (1995) Dominance and elitism: the modern health care system in Nepal. In Global Perspectives on Health Care, eds E. B. Gallagher and J. Subedi, pp. 73-82. Prentice Hall, Englewood Cliffs, NJ. United Nations (1980) Population of Nepal. United Nations Economic and Social Commission for Asia and the Pacific, Bangkok, Thailand. WHO (1978) Alma Ata 1978: Primao" Health Care. "Health for All" Series, No. 1. WHO, Geneva. WHO (1984) Social Dimensions o[" Mental Health. WHO, Geneva. Zeichner, C. I. (1988) Modern and Traditional Health Care in Developing Societies. University Pres~ of America, Lanham, MD.
Soc. Sci. Med. Vol. 45, No. 3, pp. 441-447, 1997 © 1997 Elsevier Science Ltd All rights reserved. Printed in Great Britain 0277-9536/97 $17.00 + 0.00
THE M O D E R N MENTAL HEALTH SYSTEM IN NEPAL: ORGANIZATIONAL PERSISTENCE IN THE ABSENCE OF LEGITIMATING MYTHS MARK TAUSIG'* and SREE SUBEDI 2 'University of Akron, Akron, OH 44325-1905, U.S.A. and -'MiamiUniversity, Oxford, OH, U.S.A. Abstract--This paper advances an organizational explanation for the slow pace of modernization of mental health care systems in developing societies. In complement to cultural and political economic explanations of this condition, we suggest that the value of establishing modern systems in developing societies lies in the legitimation such structures provide for indigenous modernizing efforts vis-d-vis both indigenous and external audiences. The system need not meet actual levels of service demand. Its importance is in its symbolic value as an indicator of modernity. The result is a system in "permanent failure". Implications for institutional theory and the growth of modern mental health systems in developing societies are discussed. © 1997 Elsevier Science Ltd Key words--mental health, developing societies, institutional theory
INTRODUCTION
The creation of modern systems of mental health care in developing countries is becoming a matter of great concern and interest. It is estimated that mental health problems directly account for 8.1% of lost years of quality of life and are indirectly associated with another 34% of disability conditions (Desjarlais et al., 1995). Despite commitments from a large variety of funding sources in the developed world, modern mental health systems in developing societies are poorly established and have grown slowly. The question is, "what explains the slow process of establishing modern health care systems in developing societies?" In this paper we will explore the utility of an answer based on a social institutional explanation. We argue that existing cultural and political economic explanations, while necessary, are not sufficient to account for the observed state of development of modern health systems. Indeed, while such explanations address barriers to development and the functional "failures" of modern systems, we will also suggest that failed systems may represent successful symbolic institutional exemplars of modernization. In this respect, the slow development of a modern system of health care masks the successful symbolic value of adopting a modern form of social organization. We wilt discuss the modern mental health care system of Nepal as an example of an organizational form that exists in a state of "permanent failure" yet which provides legitimation to modernizing efforts in that country. We will show that the pre*Author for correspondence.
441
sence of a modern mental health system per se, regardless of its actual size or corresponding relationship to need, legitimates the general societal enterprise of modernization. In doing so we observe an interesting reversal of a causal sequence specified in institutional theory (Meyer and Rowan, 1977) in which new organizations derive legitimacy from adopting structural forms that are isomorphic with prevailing forms (i.e. bureaucratic, rational). In the case at hand, the sequence is more complex and nonrecursive. The modern organizational form legitimates a new cultural myth in the developing society as well as legitimating the efforts of the society in the eyes of external (modern) social systems. The institutional perspective can, therefore, be used to explain the weak development of modern organizational forms in developing societies a n d their persistence despite this weakness.
BACKGROUND
Improvement of the health status of the general population is a central goal in virtually all developing nations of the world (WHO, 1978). To this end most of these countries have borrowed and adapted Western medical techniques and technology to some degree. Generally, modern health systems are employed as a means for reducing infant mortality, improving basic sanitation practices and reducing the incidence and prevalence of infectious disorders. At the same time, the goal of health for all by 2000 is clearly not likely to be reached. Several general reasons have been proposed to explain this expected outcome. First, there is the issue of cultural contradictions. Discrepancies
442
Mark Tausig and Sree Subedi
between modern and indigenous understandings of health, illness and treatment are well-known (Kleinman, 1980). Indigenous explanations for the causes of sickness, the relationship between mind and body and the culturally appropriate forms of intervention can generate resistance to western forms of health care, reduce its use and undermine the continued growth of modern systems (Zeichner, 1988; Subedi, 1989; Gallagher, 1993). Modernization itself represents a set of cultural assumptions, values and beliefs as well as material changes and these may clash with indigenous assumptions, values and beliefs. Cultural resistance to either the specific explanations for illness or the implications of modernization in general can slow or stop the development of modern health systems. Political economic arguments are also well-established as explanations for underdevelopment. As a rule these arguments are based on the economic dependence of developing societies on developed societies in the world system (Navarro, 1986; Alubo, 1993; Reich, 1993; Desjarlais et al., 1995). One of the defining characteristics of developing societies is the absence of indigenous capital with which to modernize the existing social and economic infrastructure and to create the organizational resources necessary to establish an enterprise as sizable as a health care system. Typically, developing societies make use of loans and grants from developed countries to create these systems. World systems theorists argue that financial institutions such as the World Bank and International Monetary Fund (as well as governmental and private sources of "foreign aid") use their control of economic resources to maintain a domination-subordination relationship between donor and donee. They emphasize economic activity in developing countries that is considered valuable to economic interests in the developed world as opposed to the well-being of individuals in developing societies. In other words, health and health care systems in developing countries are not a high priority for funding agencies in developed countries. It is only recently that the World Bank has "discovered" the importance of health as a focus for investment (Hecht, 1995). Even then, funders prefer to channel their financial support through "financially responsible" conduits (Atkinson, 1995). Developing societies themselves also establish priorities for development (Desjarlais et al., 1995). This is done partly as a function of the scarcity of economic resources and partly as a function of internal political concerns. Thus, the creation of a comprehensive and ubiquitous health care system may have a lower priority compared with the development of the physical infrastructure or the creation of viable economic organizations. Third, the perceived importance of physical health as opposed to mental health as a priority in developing societies serves to restrain the growth of
mental health systems (Desjarlais et al., 1995). It is only in the last few years that the extent and severity of mental health problems in developing societies has begun to be systematically described and regarded as an important health problem (Harpham, 1994). This "bias" mirrors the relative neglect of mental health systems in developed societies. It is also related to modern funders' standards for assessing health status in developing societies in terms of infant mortality, control of infectious disorders and population growth but not in terms of psychological well-being. Cultural incompatibility, the world and domestic political economies and internal developmental priorities are most useful for explaining the absence of modern systems. They do not do as well for explaining why a modern mental health system exists at all or why it might exist at a very low level of development. These questions require a fourth account centered on the symbolic importance of modern forms in developing societies. It is from such accounts that we will construct an institutional argument to systematize the relationships among all the proposed explanations for the underdevelopment of health systems. On one level the adoption of modern medical practices is based on its demonstrated effectiveness. The adoption of a modern medical philosophy, however, also includes the institutionalization of a form of organization that is based on an ideology of western bureaucratic rationality. Modern health systems are symbolic "carriers of modernity" (Phillips, 1990; Gallagher, 1993). In this sense, such systems legitimate the general process of modernization within the developing society. The material success of modern medical processes facilitates the symbolic acceptance of the underlying form of organization that supports this material success. Such legitimation has benefits for the state and is, therefore, supported by the state (Frank, 1988). Frank argues, for example, that modern medical systems legitimate the expansion of the state for other purposes, as well. Thus, the state and medical systems provide legitimation for one another. The legitimation of the enterprise of modern health services in developing countries like Nepal can initially only be established by reference to modern societies with a firmly based institutional ideology using rational principles. To some degree there will otherwise be cultural contradictions between existing forms of social organization and those based on bureaucratic principles. The advantage of using such an organizational principle in developing nations, however, lies not only in its internal social, economic, and political value as an indicator of the progressive modernization of the society but also in the legitimating function it plays in attracting funds and personnel from developed societies. Alubo (1993), for example explains that a developing country must satisfy the symbolic expec-
The modern mental health system in Nepal
443
In many developing societies modern and indigenous forms of organization coexist. This coexistence can be seen as a means for maintaining traditional cultural identities while simultaneously providing openings to modernity. In this regard the existence of modern organizational forms cannot be legitimated in terms of indigenous cultural systems but only with reference to modern systems. The presence of mimetic (imitative of modern forms) organizational systems also helps to legitimate the socioeconomic and political enterprise of modernization within developing countries by providing concrete examples of development for the indigenous population. The presence of these organizations fuels external investment in the developing country. The enterprise of modernization generates both socioeconomic and political capital in developing countries through the legitimation accorded to activities that mimic those of developed societies. The result points to the importance of socioeconomic and political factors for development, but in an unusual way. What is different about this analysis is the manner in which the existence of modern organizational forms are explained and their effects on the economic and political behavior of the state. Figure 1 shows that indigenous modern organizations derive their legitimacy from mimetic correspondence with modern organizational forms. This initial cognitive legitimacy can then be used to generate socioeconomic and political legitimacy for indigenous modernizing political elites who, in turn, gain cognitive and socioeconomic legitimacy from developed countries that can be converted into
tations of western financial interests in order to receive continued financing. Hecht (1995) and Atkinson (1995) make it clear that organizations such as the World Bank and Save the Children Fund make funding decisions based on perceptions of the legitimacy of efforts to establish modern systems. In turn, the ability of a developing society to satisfy external funders, enhances the internal political position of the State (Alubo, 1993).
AN INSTITUTIONALEXPLANATION These observations about the symbolic importance of modern organizational forms can be systematically integrated with the previous recognition of cultural and political economic barriers to modernization to obtain a more complete explanation for the fate of modern health care systems in developing societies. The institutional theory originally outlined by Meyer and Rowan (1977) and elaborated by them and others (Meyer and Scott, 1983), seeks to explain why organizations in modern society have such uniform surface structures despite wide variations in technical processes and objectives. It is argued that all organizations must obtain cultural legitimation for their activities by adopting the appearance of formal rationality, the institutional myth prevailing in the "modern" cultural environment. Demonstrating organizational conformity to this institutional myth confers legitimacy on the organization and improves its chances of survival and access to social resources.
Indigenous Societies Cognitive Legitimacy °ci°-P°liticalLe gitimacy
~
Indigenous Elite Stability (Sourcesof Rational-Legal Formsand Economic Resources)
Cognitive Legaimacy L
(CognitiveLegitimacy ~ acquit, by form) assoming
~ "~~Ind~gre
Socio-Economic Political Legitimacy
/ /
~ , ~ t M ~ ern
Fig. 1. A nonrecursive model of the relationship between legitimating sources and organizations in developing societies.
444
Mark Tausig and Sree Subedi
development projects which enhance indigenous legitimacy. Ordinarily in institutional analysis the adoption of rational ceremony by an organization serves to legitimate goals of the organization and its existence. For example, mental health services in modern societies are acceptable as an organizational activity partly because the activity is conducted within an acceptable organizational structure. However, in the case examined here it is clear that the adoption of a specific rational organizational myth and form does not lead to the extension of mental health services in any way that indicates organizational success. The reason for this is that the organizational enterprise itself and the actual delivery of specific organization outputs such as mental health services is of secondary importance to the symbolic legitimation of socioeconomic and political activities. In light of the previous discussion, it should now be clear that institutional theory can be used to integrate cultural and political economic arguments regarding modernization and barriers to modernization with observations about the symbolic meanings of modernization processes. It is time to turn to a case study of a modernizing society to examine how these processes work in an actual situation. THE M O D E R N MENTAL H E A L T H SYSTEM IN NEPAL
Nepal is a society undergoing a transition toward a "modern" social system. The development is, however, uneven. This is partially owing to the fact that Nepal remained relatively isolated until 1951 and exposure to western or modern ideas and ideals was limited (Subedi, 1989). Exposure is thus relatively recent and largely confined to the urban population of Kathmandu, although it has had some effect on other towns and rural areas owing to the influence of the mass media and the influx of tourists. In some places this has resulted in out-migration pressures and disruption of traditional village stability. In spite of this, traditional (Hindu) Nepali society is almost intact in the majority of the country. In the summer of 1994, extensive interviews were conducted with government officials, facility directors and facility staff in order to understand the organization and practice of modern mental health services in Nepal. Documents pertaining to planning, need and utilization were also obtained where possible. All interviewing was confined to Kathmandu which is the only location where modern mental health services are available within the country. Indigenous and modern mental health care systems coexist. Most of the indigenous mental health care is provided by folk practitioners known as Jhankries and Dhamis. According to Streefland (1985) (p. 1155), "the most widely prevailing medi-
cal system in Nepal is faith-healing", and it is strongly rooted in the minds of most people. In Nepali society, traditional cultural institutions continue to dominate the explanations of the causes and care of persons regarded as "mentally ill" by modern forms of assessment. Hence, faith healers such as Jhankries and Dhamis receive wide public acceptance and play a significant role in meeting the health care needs of the population (UN, 1980). For example, Achard (1983) reports that a patient in a hilly region of Nepal is more likely to contact a Jhankri/Dhami for a mental health problem than any other health services provider. In Nepali folk medicine symptoms of distress are both somatic and psychological and are explained as attacks or possession by demons, ghosts or spirits. The origins of these attacks or possession may be the random malevolence of ghosts etc. or may result from conflicts within the community which cause an aggrieved party to direct a demon to bring misery to a member of the responsible family. Regardless of the specific cause, a family may hire a Jhankri or Dhami to expunge the demon and cure the patient. It is generally the case that patients who utilize the modern forms of health treatment in Nepal have visited indigenous healers prior to seeking modern forms (Subedi, 1989, 1992; Subedi and Subedi, 1995). The modern trained psychiatrists in Kathmandu report no conflicts with folk healers and, indeed, have found them to be cooperative in that Jhankries/Dhamis sometimes refer patients to the modern mental health system. This suggests that cultural contradictions alone cannot explain the utilization and extent of modern mental health services. While modern forms of medical treatment remain foreign to most people, the extent to which cultural contradictions function as an actual barrier to utilization of modern health services is questionable. Moreover, patterns of utilization of existing modern health services suggest that they are mostly used by economic and political elites who are highly supportive of modern cultural values (Subedi and Subedi, 1995). The modern mental health system in Nepal began in 1962. At present, the complete modern mental health system (that is, agencies which use standard ICD/DSM diagnostic categories, standard psychopharmacology and employ trained psychiatrists) consists of one 40 bed acute care facility and its allied outpatient department. In addition, there are two 12 bed wards at the general hospital and the teaching hospital in Kathmandu. This latter facility is partially staffed by British psychiatrists and funded by the United Christian Mission. Further, there are four to five bed wards in the military hospital and two regional hospitals. A small community mental health program has also been established at three regional hospitals. Finally, there is a limited program (funded by the United Mission) to teach modern-trained health pro-
The modern mental health system in Nepal fessionals to screen for mental health problems. The acute care hospital was started in 1984 and the teaching hospital ward was established in 1987. There are a total of 13 trained psychiatrists in the country, all working in Kathmandu. The mental health care units outside Kathmandu are run exclusively by personnel and/or physicians who are not trained in psychiatry. No services exist for the chronically mentally ill. The acute care hospital admits patients in active psychotic states who appear to be in imminent danger to themselves or others. Often families bring patients from rural areas which may require several days' journey. Diagnosis is perfunctory and used as a general indicator for treatment course. The main objective is to restore some degree of "insight". Electroshock treatments are given to 20-30% of patients and the average length of stay is three to four weeks. The hospital admits 500-550 patients per year and there is a readmission rate of 70%. While treatment and medication are free in the hospital, the patient must pay for medicine after leaving the hospital. The outpatient department functions six days per week and treats approximately 8000 patients per year, most on a regular basis. Treatment is largely medication based. The psychiatric wards at the general hospital and the teaching hospital do complete diagnostic workups of their patients and provide treatment according to standard western protocols. Psychiatrists report high levels of conversion disorders and hysteria, reflecting the absence of a cultural distinction between mind and body. The teaching hospital also has an active program for training medical personnel to screen for psychiatric disorders. They have developed a short screening form for identifying epilepsy (recognized as a mental disorder in Nepal), depressive disorders, psychoses and antisocial personality disorders. Identified cases are referred to the mental health unit of the teaching hospital. At the national planning level very few resources are devoted to mental health. Government priorities are clearly directed toward health programs to reduce infant mortality, infectious diseases and parasitic disorders (Subedi and Subedi, 1993). Nepal's infant mortality rate is among the highest in the world and life expectancy is among the shortest. Nepal receives substantial external funding for programs which address these problems. The health department has no epidemiological data regarding prevalence or incidence of mental disorder. The World Health Organization collaborated in a smallscale survey in 1987 and the findings from this survey are the sole scientific data available for planning. A separate line for mental health services in the national health budget was only established in 1984. This money supports the psychiatric ward at the general hospital, the acute care hospital and the training of two psychiatrists per year in India.
445
There is only a vague recognition at the governmental level of the extent and impact of mental health problems. Despite this, however, the state officially endorses the development of a modern mental health system and regards its efforts as part of societal modernization efforts. To summarize, a modern mental health system has been established in Nepal but it is clearly inadequate to meet the mental health needs of the population, which have also not been clearly identified. Its growth has been stagnant. It persists, but does not thrive or develop. Evidence suggests that, despite culturally different views of mental illness, indigenous and modern systems of mental health services are not in conflict with each other. Owing to the absence of conceptual antagonism, cultural resistance cannot fully explain the failed state of development of the modern mental health system. The mental health system is also seriously underfunded and this is clearly a function of externally driven (western funding sources) health status goals as well as objective conditions. Progress in reduction of infant mortality, decreases in rates of infectious and parasitic disorders, contraception programs, etc. are clearly regarded as markers of modernity and development by the Nepali government as well as more developed societies. The bulk of modern health care funding is directed toward these objectives. At the same time mental health services are regarded generically as part of a modern health care system and there are some external funds available for mental health services. The modern health care system in Nepal cannot be regarded as fully developed so that one can argue that it also suffers from organizational failure along lines very similar to those we have identified for mental health services. The overall poverty of the society cannot be entirely dismissed as an explanation for the under-development of modern social institutions. This account of the modern mental health system in Nepal makes it clear that issues related to cultural contradiction and/or political economy cannot alone explain the organizational status of the mental health system. In Nepal the modern mental health system exists in a cultural environment that values the symbolism of modern rational forms but does not value the organizational goal. In other words, the purpose of the organization is legitimated by reasons external to the indigenous institutional ideology and the organization's officially stated goals. More specifically, we suggest that the establishment of a modern form of a mental health system may serve the need for indigenous political economic elites to demonstrate their modernity to the developed world in order to obtain external legitimacy. This, in turn, will attract foreign investment and aid the social, economic, and political institutions of the society to align with a modernizing ethos. It is clearly possible for societies to import
446
Mark Tausig and Sree Subedi
the structural trappings of modernity (mimetic isomorphism of a modern mental health system) without the cultural underpinnings that are thought to give rise to the form. Such forms receive legitimation simply because they represent "modernity" and adoption permits the society to measure its level of modernity. The status of western-oriented "modern" mental health systems in many developing countries is markedly under-developed despite recognition of the high prevalence of mental illness (WHO, 1984). Institutional theory suggests that the success of organizations is partially a function of the isomorphism of their organizing rationale with legitimating myths about what constitutes proper form. In developing societies, such as Nepal, however, indigenous organizing rationales are not consistent with the survival of modern organizational forms. Rather, institutional myths of developed societies are generally admired and the presence of exemplars of modern organizations have enormous symbolic value as indicators of modernization. This admiration is not sufficient to create a thriving modern system, however. All that is needed to acquire this symbolic value is a minimal modern mental health system, one that may be described as being in a state of permanent failure characterized by high persistence and low performance (Meyer and Zucker, 1989). IMPLICATIONS FOR INSTITUTIONAL THEORY
This institutional analysis shows the involvement of socioeconomic and political processes in development but puts the outcome of establishing modern organizational forms related to development in a different light. These forms become independent predictors of socioeconomic and political development rather than results of such development. This argument explains why the mental health system is so small and inadequate in Nepal despite the need for mental health services. The usual institutional analysis assumes a causal progression in which a newly founded organization engages in a strategy designed to earn cultural capital and thus, obtain legitimacy from the external environment (Aldrich and Fiol, 1994). From this perspective the weak, under-developed nature of the modern mental health system in Nepal appears as a struggle for legitimacy by a culturally alien form with very limited cognitive or sociopolitical legitimacy. This causal assumption suggests that, over time, the mental health system may enlarge and increase its effectiveness as a function of general development in Nepal along western/modern lines. The general absence of the rational-legal form in traditional Nepalese society calls the accuracy of this causal ordering into question in the present case. Meyer and Rowan (1977) argued specifically that the legitimating effects of adopting the prevail-
ing organizational myth only operate within modern institutional systems. In developing societies, rational forms (such as the modern mental health system) are established mimetically to generate socioeconomic and political legitimacy for indigenous modernizing elites. In turn, the mental health system is then granted cognitive legitimacy by these sociopolitical elites. The application of the institutional approach to the question of why modern mental health services exist in the form they do can, therefore, be used to extend institutional theory. The analysis suggests the socioeconomic and political importance of gaining cultural legitimation and capital through the use of rational myth and ceremony but not just for a specific organization. Cultural capital is an apt term for the fruits of this type of legitimation. By reversing the causal order and using rational form to explain economic and political resource conditions, we can see that institutional theory's reach can be extended to analyze issues of modernization. In Meyer and Rowan's (1977) original formulation of institutional theory, modernization is an assumed prerequisite for explaining institutional isomorphism. We can now see that this isomorphism has generative properties of its own. This paper offers additional openings for the application of institutional theory by suggesting ways in which it can be applied to understanding the modernization process itself as well as the consequences for organizational forms and the role that isomorphism plays in the survival of organizations. Specifically, we suggest that there can be a nonrecursive relationship between organizational form and legitimation such that the existence of the form can sometimes confer legitimacy on the organizing ideology. Institutional theorists and organization ecologists have not examined this possibility because it is implausible given their causal assumptions. The extension of the theory cannot be fully tested without more cases and the passage of time. We need to observe a concomitant growth of rational legal forms in general and in the mental health system and we need to see it under varying internal and external political economic conditions.
IMPLICATIONS FOR THE DEVELOPMENT OF MENTAL HEALTH SERVICES
The mental health status of populations in developing societies is largely unknown. The World Health Organization (WHO, 1984) estimates that 20% of those who seek general health services present with mainly psychosocial problems and mental health is part of the official WHO definition of health. The WHO cites unchecked urbanization, destruction of traditional family life, mass migration, violence, crime and economic hardship as common stressors in developing countries. T h e s e factors are linked to increased rates of drug and
The modern mental health system in Nepal alcohol abuse, as well. Despite this understanding, mental health services are clearly underdeveloped in most modernizing societies. This situation is clearly a function of the funding and value priority that physical health needs have for both developing and developed countries. Cultural explanations for mental disorder also affect the "fit" between modern therapeutic techniques and those of other societies. On the contrary, modern mental health systems do exist in most developing countries but are under-developed. In this paper we have argued that one reason for this situation is the legitimating function that a modern organizational form plays in modernizing social systems. To the extent that mental health systems serve a symbolic rather than a functional purpose, we should not expect development of the system to parallel general material development. The growth and development of modern mental health systems will, for the time being, continue to depend on their value as a source of cognitive, socioeconomic and political legitimacy within the country as well as their ability to draw resources into the country from external sources. Mental health systems will neither disappear nor expand to the level required to address actual levels of psychological disorder in the population. Acknowledgements--The authors would like to thank their informants in Nepal and Mr. Bimal Pandey for his assistance in collecting data for this study. The advice of reviewers from this journal has also significantly improved the work. REFERENCES
Achard, T. (1983) Primary Health Care & the Hil& of Nepal. His Majesty's Government (HMG/SATA): Integrated Hill Development Project (IHDP), Kathmandu, Nepal. Aldrich, H. E. and Fiol, C. M. (1994) Fools rush in? The institutional context of industry creation. Academy of Management Review 19, 645-670. Alubo, S. O. (1993) Implementing health for all in Nigeria: problems and constraints. In Health and Health Care in Developing Countries, eds P. Conrad and E. B. Gallagher, pp. 228-245. Temple University Press, Philadelphia. Atkinson, S. J. (1995) Non-governmental organizations at the interface between municipalities and communities. In Urban Health in Developing Countries: Progress and Prospects, eds T. Harpham and M. Tanner, pp. 182200. St Martin's Press, New York. Desjarlais, R., Eisenberg, L., Good, B. and Kleinman, A. (1995) Worm Mental Health: Problems and Priorities in Low-Income Countries. Oxford University Press, New York.
447
Frank, J. (1988) Medical modernization in Mexico: paradigrns, labor markets and the state. In Modern and Traditional Health Care in Developing Societies, ed. C. Zeichner. University Press of America, Lanham, MD. Gallagher, E. B. (1993) Modernization and medical care. In Health and Health Care in Developing Countries, eds P. Conrad and E. B. Gallagher, pp. 285-306. Temple University Press, Philadelphia. Harpham, T. (1994) Urbanization and mental health in developing countries: a research role for social scientists, public health professionals and social psychiatrists. Social Science & Medicine 39, 233-245. Hecht, R. (1995) Urban health--an emerging priority for the World Bank. In Urban Health in Developing Countries: Progress and Prospects, eds T. Harpham and M. Tanner, pp. 123-141. St. Martin's Press, New York. Kleinman, A. (1980) Patients and Healers in the Context of Culture: An Exploration of the Borderland Between Anthropology, Medicine and Psychiatry. University of California Press, Berkeley. Meyer, J. W. and Rowan, B. (1977) Institutionalized organizations: formal structure as myth and ceremony. American Journal of Sociology 83, 340-363. Meyer, J. W. and Scott, W. R. (1983) Organizational Environments." Ritual and Rationality. Sage, Beverly Hills, CA. Meyer, M. W. and L. G. Zucker. (1989) Permanently Failing Organizations. Sage, Newbury Park, CA. Navarro, V. (1986) Crisis, Health and Medicine. Tavistock, New York. Phillips, D. R. (1990) Health and Health Care in the Third WorM. Wiley, New York. Reich, M. R. (1993), The political economy of health transitions in the Third World. In Health and Social Change in International Perspective, eds L. C. Chen, A. Kleinman and N. C. Ware, pp. 411 451. Harvard University Press, Cambridge, MA. Streeftand, P. (1985) The frontier of modern western medicine in Nepal. Social Science & Medicine 20, 1151 1159. Subedi, J. (1989) Modern health services and health care behavior: a survey in Kathmandu, Nepal. Journal o! Health and Social Behavior 30, 412-420. Subedi, J. (1992) Primary health care and medical pluralism exemplified in Nepal: a proposal for maximizing health care benefit. Sociological Focus 25, 321-328. Subedi, J. and Subedi, S. (1993) The contribution of modern medicine in a traditional system: the case of Nepal. In Health and Health Care in Developing Countries, eds P. Conrad and E. B. Gallagher, pp. I10 121. Temple University Press, Philadelphia. Subedi, S. and Subedi, J. (1995) Dominance and elitism: the modern health care system in Nepal. In Global Perspectives on Health Care, eds E. B. Gallagher and J. Subedi, pp. 73-82. Prentice Hall, Englewood Cliffs, NJ. United Nations (1980) Population of Nepal. United Nations Economic and Social Commission for Asia and the Pacific, Bangkok, Thailand. WHO (1978) Alma Ata 1978: Primao" Health Care. "Health for All" Series, No. 1. WHO, Geneva. WHO (1984) Social Dimensions o[" Mental Health. WHO, Geneva. Zeichner, C. I. (1988) Modern and Traditional Health Care in Developing Societies. University Pres~ of America, Lanham, MD.