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Cambodia had suffered enormously due to war and internecine conflict during the latter half of the twentieth century, more so during the Vietnam War. Total collapse of education and health systems during the Pol Pot era continues to be a challenge for developing the necessary infrastructure and human resources to provide basic minimum mental health care which is compounded by the prevailing cultural belief and stigma over mental, neurological and substance abuse disorders (MNSDs). The mental health research and services in Cambodia had been predominantly 'trauma focused', a legacy of war, and there is a need to move toward epidemiologically sound public health oriented mental health policy and service development. Integrating mental health program with primary health care services with specifically stated minimum package of activities at primary level and complementary package of activities at secondary level is an opportunity to meet the needs and rights of persons with mental, neurological and substance abuse disorders (PWMNSDs) in Cambodia, provided there is mental health leadership, government commitment and political will.

Cambodia is a developing south-east Asian country located in the fertile Mekong delta. Its recent past has been complicated by European colonialism and internal conflict. Health including mental health services are limited and sparse in regional and rural areas. Very constrained public mental health facilities and services are hampered by a shortage of a skilled workforce and insufficient training programs. The recent formation of the Mental Health Association of Cambodia promises to be a positive step forward in promoting mental health throughout the country.

There are 35 countries and territories that make up the Western Pacific region of the World Health Organization (WHO). Of these, the 14 Pacific Island Countries (PIC) can be categorized as low or medium income and developing countries. The populations range between 10,000 and 250,000; their per capita GNP is mostly well below US $4000. Although independent decades ago from the many colonial powers, their progress in economic and health care development has been slow and fragmentary. There are challenging reasons for this. The island countries mostly have dozens of thinly populated islands separated by hundreds of kilometers of ocean. Cook Islands, for instance, has 15 populated Islands totaling about 250 square kilometers of land in 2 million square kilometers of sea and hundreds of kilometers of sea separating the islands. Sea transport between the islands is slow and expensive. Air travel is prohibitively expensive and infrequent. Fish, the only currently exploitable resource is exploited by huge fishing fleets with mother and processing ships from north Asia, which pay nominal fees for the license to fish in the economic zones of the developing countries. The health care systems have innovated local systems to overcome these real problems. Among them has been the fairly good training of registered nurses, nurse practitioners, and systems of contact by telephone, and email in recent times (and radio telephone in past years) to get assistance in diagnosis and treatment for the widely separated small hospitals and clinics. Few are able to afford helicopter evacuations of seriously ill persons and only a few dire emergencies are evacuated through the infrequent commercial flights on small aircraft that serve the outlying areas. The small hospitals in the largest islands have relatively few doctors and even less specialists, many of whom are expatriates as local training of doctors is limited to only 2 established medical schools – one in Fiji and the other in Papua New Guinea for the whole region of 14 developing countries. Most medical students are on scholarships as fees are prohibitive. Perhaps the most serious casualty is the mental health services of these 14 PICs. There are only about 12–15 psychiatrists in the 14 countries for about 8 million people. All of the psychiatrists are in the capital cities of 5 of the 14 countries and at least 6 of the 14 countries do not even have a qualified psychiatric nurse. At least 4 have small mental hospitals that have for the most part been badly run and continue to institutionalize the pervasive stigma of mental illness with locked wards, barbed wire and incarcerated patients.

Vietnam is a large largely tropical country of well over 90 million people in the heart of southeast Asia. Although its ancient history is well over 2500 years old it is Vietnam’s recent past that the world is more aware of. Few in modern times have heard of the ancient Dong Son Drums or the ancient Cham empire that ruled over parts of neighbouring countries besides south Vietnam Following World War II the Vietnamese communist party under the leadership of Ho Chi Minh opposed the return of the French colonial power who had ruled French Indochina prior to the war. The guerilla war that followed ended in the northern part of the country with the fall of the large French base at Dien Bien Phu in 1954 and the talks that followed led to the division of the country into a North Vietnam and a South Vietnam below the 17th parallel. The south was ruled by the French and later a Vietnamese government. The guerilla army continued the struggle into the south when the French left Vietnam and this led to a huge intervention by the US and its allies who were defeated in 1975. Vietnam was once again reunited in April of 1975. Since the reunion of Vietnam and despite tremendous war damage, privation and damage to infrastructure the united country has re-built the country almost from scratch, and started to heal the wounds of over 30 years of war by Japan, France and the US. Today Vietnam has the fastest growing economy in southeast Asia and striving to develop its war deprived social and health care training and services. There were big differences in the health and mental health services in the south and the north. While the North after the departure of the French patterned its mental health training and services on socialist models learned from China and Russia, the South depended on a more western model of the 1950s. Thus in 1975 there were in place 2 different systems of mental health care – one for the North and one for the South. The one in the north relied on 2 large mental hospitals in Bien Hoa near Saigon (now renamed Ho Chi Minh City) and one for the central provinces in Da Nang. The concept of Community care and district level mental health care and psychiatric beds outside of the 2 large mental hospitals was very limited. The problems in the South were largely that of very limited trained human resources as French trained psychiatrists were scarce beyond the budget of the ministry of health. In the North however a rough and ready system training of new medical graduates with less than 1 year of training in psychiatry, training of Feldshers or Medical assistants as front line mental health workers was put in place after 1954 by the newly independent Vietnam. It covered cities, towns and villages. While the training was basic and available in the North, the services were hospital based and specialised but largely unavailable to those outside of the 2 large mental hospitals of the South. Post-1975 the re-united government of Vietnam embarked on a two pronged approach to enhance mental health training and services. The mental health services were extended to most parts of the country up to subdistrict level. At the level of mental hospitals 35 were set up with over 5000 beds including 3 under Ministry of Health. A further 6000 beds are under ministry of Labour, Veterans affairs and Social welfare. A further 21 psychiatric wards are integrated into provincial level general hospitals in Vietnam. The move to provide community care for the mentally ill covers 56 of the 64 provinces and some 1305 of the 11500 subdistricts have subdistrict level mental health services. Plans are under way to extend the provision of mental health care to more centres at the subdistrict level. To train mental health human resources a variety of training programmes spearheaded by the Institute of mental health and the First National Psychiatric Hospital in Hanoi have organised an elaborate training system. The psychiatrists today number 850 of which 400 are postgraduate level trained mostly at the Institute of Mental Health at the Bach Mai hospital in Ha Noi. The Institute of Mental Health with 50 staff including 20 psychiatrists and 165 inpatient beds has a busy training programme including training for over 500 medical students, 200 nurses and traditional medicine students. There are also 15 PhD and 50 Masters students. The institute works closely with the 500 bedded First National Psychiatric Hospital and the Armed forces medical college in Hanoi. With such an elaborate network of mental health service centres there is a need for quality assurance and training of human resources. In the past with independence the only source of assistance from overseas was from socialist countries and several of the senior staff were trained in Russia, Germany, PR China and Eastern Europe. In recent

Fiji is a developing country in the south Pacific with a population of 850,000 made up of Fijians (60) and Indians (40%) that gained its independence from Britain over 40 years ago. The economy with a per capita income of over 3000$US that was dependent on sugar production and exports has in recent years undergone major structural changes and changes in government. There have been difficulties in maintaining social services and in providing services in the widely separated areas of this country of over 300 islands. The mental health services have almost entirely been based in the now 127-year-old St Giles hospital in Suva. The first attempt to decentralize services in mental health came after several WHO reports in 2005 when a psychiatric clinic was started in Labasa on Venua Levu Island every two months Since then about eight such clinics are held every 2–3 months. These have largely been ineffective as the patients cannot afford to or are too ill to be transported from as far as 300 km away by road or ship or plane to St. Giles hospital in Suva where there are two psychiatrists. The Fiji School of Medicine itself over 125 years old now has two psychiatrists and for over 19 years had only one. The Fiji school of medicine takes in about 80 medical students from a dozen countries in the Pacific and has trained hundreds of doctors for the developing countries of the Pacific. The Fiji school of Nursing, at least 80-year old, has also been a premier training school of nurses in the Pacific until other countries started their own schools of Nursing. Themental health services based in St Giles and depends on just two psychiatrists have been recognized to be very unsatisfactory for many years but the lack of local government commitment to change has left it stigmatized and marginalized in the context of health care. Although the other disciplines have had regular input from the affluent countries of Australia and New Zealand through medical and surgical teams coming regularly to support Fiji’s limited medical and surgical expertise, Psychiatry never had these benefits until 2008 when Volunteer psychiatrists from the Indo Australian Psychiatric Association came to Fiji to help with clinical work in Labasa, Lautoka and Suva a few times a year With this situation the Minister of Health of the Republic of Fiji approached the founder of the Asian federation of Psychiatric Associations to support and provide assistance: (1) to develop the Post graduate program in Psychiatry to train psychiatrists for Fiji; (2) to review and revamp the medical students and nurses in psychiatry at the Fiji school of Medicine and Fiji school of nursing

The 14 low and medium income countries (LAMICs) of the western Pacific Ocean consist of thousands of large and small islands in Polynesia, Micronesia and Melanesia scattered over millions of square kilometres of sea. Although economically not confronted with the problems of the poorest low income countries, the western Pacific Ocean nations face the communication, transport and infrastructure difficulties of this geographical and demographic dispersion. For example, the Cook Islands in Polynesia have approximately 22,000 people on 15 populated islands with a total land area of approximately 250 square kilometres in more than 5 million square kilometres of ocean. In addition to the problems created by distance, mental health services have often been marginalised in resource allocation resulting in a scarcity of trained personnel and facilities. The dearth of mental health clinicians has also been exacerbated by their emigration to high income countries resulting in some seven western Pacific countries having no psychiatrist or psychiatric nurse. Nonetheless, in most regions there does remain an adequate number of primary health clinicians, both doctors and nurses, who treat the mentally ill, albeit it reluctantly. The reluctance emanates from a lack of training and a pervasive social stigma toward the mentally ill culminating in many clinicians refusing to attend to psychiatric disorders in their daily work in many island nations. Whereas patients from a consolidated land mass confronting this prejudice may overcome it by seeking help relatively easily elsewhere, through road travel, the prohibitive financial and time costs and dangers associated with air and sea travel limit this solution in the Pacific islands. Alternatively, the only recourses for the psychiatrically ill are traditional healers or the use of police to restrain violent or aggressive behaviour. A practical solution to the parlous state of mental health care in many western Pacific Ocean nations is to utilise primary health clinicians. However, for this to occur primary health clinicians need basic psychiatric training and a positive attitudinal change to those with mental illness.