Egyptian Journal of Psychiatry

: 2012  |  Volume : 33  |  Issue : 2  |  Page : 74--82

The Egyptian law 71/2009 ‘Care of mentally ill patients’ ( knowledge and opinions of service providers, relatives, and patients with substance abuse)

Aref Khoweiled1, Dalal Amer1, Manal Abed2, Osama Refaat1, Tamer Goueli1, Emad Hamdi1,  
1 Department of Psychiatry, Cairo University, Cairo, Egypt
2 Department of Psychiatry, Mental Health Secretariat, Ministry of Health, Cairo, Egypt

Correspondence Address:
Aref Khoweiled
MD, Assistant Professor of Psychiatry, Faculty of Medicine, Cairo University, Cairo



The new Egyptian law for the care of the mentally ill has set strict criteria specifying the circumstances under which a person can be involuntarily detained in mental health institutions. The New Law does not specify whether addiction, as a psychiatric disorder, should be treated differently from other psychiatric disorders. Since the law was decreed by Parliament, the number of admissions of patients with drug addiction has reportedly declined.


To explore the knowledge and attitude toward the New Law ‘Law for the Care of the Mentally Ill Patient’ (71/2009) among service providers, patients, and patients’ relatives and how it is perceived to have affected the service to addiction patients.

Participants and methods

A total of 505 patients with substance misuse, 213 relatives, and 172 substance misuse healthcare workers (providers) were assessed using specially designed questionnaires.


More than 90% of service providers had heard about the new mental health law in Egypt. More than 50% of substance users and their relatives were not aware of it. About two-thirds of the patients agreed with provisions of the New Law as they relate to addiction, whereas more than two-thirds of service providers did not. Attribution of illness affected patients’ agreement with involuntary admission. More patients who agree to enforcing treatment view addiction as an illness (72 vs. 60%, &khgr;2=6.79, P=0.009). There is a dominant perception that the law does not allow involuntary admission of addiction patients for treatment (about 80% of service providers and 87% of relatives). Sixty-four percent of patients in this sample agreed on involuntary treatment for a period of time until patients can make rational decisions about their treatment and 69% of the patients’ relatives believed that the law needs to be modified to allow involuntary admission for addiction patients.


There are considerable ambiguities about the regulations of commitment for treatment as well as the duration of treatment and discharge for patients with addiction problems under the new mental health law (71/2009). This is only matched by an overall negative attitude of the studied stakeholders, especially service providers, which may be attributed in the latter case to a large gap in training.

How to cite this article:
Khoweiled A, Amer D, Abed M, Refaat O, Goueli T, Hamdi E. The Egyptian law 71/2009 ‘Care of mentally ill patients’ ( knowledge and opinions of service providers, relatives, and patients with substance abuse).Egypt J Psychiatr 2012;33:74-82

How to cite this URL:
Khoweiled A, Amer D, Abed M, Refaat O, Goueli T, Hamdi E. The Egyptian law 71/2009 ‘Care of mentally ill patients’ ( knowledge and opinions of service providers, relatives, and patients with substance abuse). Egypt J Psychiatr [serial online] 2012 [cited 2022 Dec 4 ];33:74-82
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Full Text


In April 2009, The Egyptian Parliament enforced a New Law entitled the ‘Law for the Care of the Mentally Ill Patient’. The New Law introduces strict criteria specifying the circumstances under which a person can be voluntarily or involuntarily detained in mental health institutions, an obligation upon mental health institutions to notify the national or the regional council for mental health, and in some cases, the public prosecutor within 24 h of involuntarily admitting a patient, a right to consent to treatment for ‘voluntary’ patients, an obligation on mental health facilities to inform patients of their rights, and a range of sanctions for service providers who violate patients’ rights. Article 13 specifies that involuntary admission can only take place ‘When there are clear signs that indicate the presence of severe mental illness that requires for its treatment admission to one of the mental health facilities, and in the presence of either of the following two conditions: (a) the likelihood of serious and imminent deterioration of the mental state, (b) a serious and imminent threat to the safety or health or the life of the patient or safety and the health and lives of others’ (The Egyptian Law for the Care of the Mentally Ill Patient, 2009).

The New Law does not specify whether addiction, as a psychiatric disorder, should be treated differently than from psychiatric disorders. However, the ‘Executive Memorandum’ initially stated that dependence on psychoactive drugs is not in itself a sufficient cause for involuntary admission.

Since the law was enacted, there has been a change in the number of admissions of addiction patients. The reasons for this change are not clear. It is clear, however, that they preceded the January 2011 Egyptian Revolution.

 Aim of the work

We aim to explore the extent of knowledge of the New Law among service providers, patients, and patients’ relatives and how it is perceived to have affected the service provided to addiction patients.

 Participants and methods

This study aimed to explore the effects and consequences of introducing the ‘Law 71/2009: Care of the Mentally Ill Patient’ on the admission and treatment of patients with substance use problems. The study is based on three independent hypotheses:

A significant proportion of patients with substance abuse, their relatives, and their mental health service providers will have no or little knowledge of the existence of the New Law.Among those who have knowledge of the New Law, a significant proportion will have an inadequate or an incorrect understanding of the articles pertaining to patients with substance misuse problems.Among those who have been subjected to the New Law, a significant proportion will report negative experiences and/or adverse consequences on the treatment process.

To ensure breadth of coverage, the study targeted three groups of stakeholders related to the New Law: patients with substance misuse problems, those currently undergoing inpatient or outpatient treatment, the relatives of patients with substance misuse problems, and the mental health service providers currently engaged in delivering inpatient treatment services for substance misuse. To sample all socioeconomic strata of society, both private and public institutions specializing in the treatment of substance misuse were included.

The Research Unit of the General Secretariat of Mental Health supervised the design of three quantitative questionnaires for the purpose of the study. Questionnaire 1 was directed to service providers working in ministry of health hospital addiction units and private hospitals with addiction units (service provider questionnaire). Questionnaire 2 was directed to patients (service user questionnaire). Questionnaire 3 was directed to patients’ relatives (relative questionnaire). Each questionnaire collected demographic information initially, followed by questions exploring knowledge of the existence of the New Law and its applicability to patients with substance misuse problems. The main body of the questionnaire aimed to explore the accuracy of information about the Law and the effects of enforcement of the Law on the patient.

All questions were quantitative, and worded in colloquial Arabic. Responses were either ‘yes’ or ‘no’ or had specific defined choices. The shared questions were partly derived from the addiction severity index (McLellan et al., 1980) and from the wordings of the Egyptian Mental Health Law (2009). The construct validity of the questionnaires was examined by two independent expert reviewers. Reviewers checked whether the questions related to the hypotheses of the study and whether they were accurately worded. The questionnaires were not tested for reliability.

A sample of 600 patients with substance misuse problems, 250 relatives, and 250 substance misuse healthcare workers were targeted. In all, 505 service user questionnaires were returned (84% response rate), 213 relative questionnaires were returned (response rate 85%), and 172 service provider questionnaires were returned (response rate 69%).

Questionnaires were distributed by hand to participants from Matar Hospital for Addiction, and the Abbassia and Maamoura Addiction unit from the public sector and to Mokattam Mental Health Hospital and two NGO addiction treatment centers from the private sector. Verbal informed consent was obtained from each participant. Participants were asked to answer the questionnaires anonymously and in private to obtain a factual independent view of opinions. A researcher was available to explain questions if necessary or read the questionnaire to those who had difficulty in reading.

The detailed characteristics of the three samples are presented in [Table 1], [Table 2] and [Table 3].{Table 1}{Table 2}{Table 3}

Statistical analysis

Data collected were transferred to an SPSS spreadsheet and analyzed using version 16 (SSPS Inc., Chicago, IL., USA). To describe and compare responses, percentages and the χ2-test were used for the nominal data. The mean and SD and a t-test or Median and U-test were used for continuous and ordinal data. P value was considered significant at less than 0.05.


The results of this study are presented in sequence according to the group of participants studied. Only the most relevant items of each questionnaire are presented in a table form. Among the items presented, there are questions that reveal knowledge, others that relate to attitude, whether positive or negative, and others that relate to actual experiences with the New Law.

Knowledge, attitude, and practice of addiction service providers

It is not surprising that the majority of service providers in the field of addiction were aware of the law (92%). A lesser proportion (73%) of nonpsychiatrist service providers had read material about the law. However, beyond superficial knowledge, less than half of the respondent service providers (45%) had received any formal training on the provisions of the law. Among psychiatrists, the higher percentage (70%) of the trained group included consultants and specialists, whereas none of the nurses (0%) had received any training (χ2=9.122, P=0.058).

There were no apparent differences between psychiatrists and nonpsychiatrists in their knowledge, attitude, or practice related to the New Law. The ‘yes’ responses of both groups were mostly in the same direction. There was one significant exception, namely, more of the nonpsychiatrists found that there was a decline in the number of patients admitted for drug misuse compared with psychiatrists (62 and 37%), respectively.

The unusual and striking findings on the views of service providers can be summarized as follows [Table 4]:{Table 4}

A large discrepancy exists between the relatively high proportions of those who know about the law and the quite low proportions of those who have a positive attitude toward the law. Positive attitudes are ascertained through agreement to unspecified questions such as ‘Do you agree with the provisions of the law’? (31.5%) and ‘Does the New Law promote better performance at work’? (31%).

There were also clear indications of misinformation and misunderstanding in the way the law provisions are perceived in relation to patients with addiction problems (statements 11–16). This is strikingly apparent in those who believe that the law does not allow compulsory admission (78%), those who believe that a patient subjected to compulsory admission has to agree with the care plan (84%), those who believe that the patient with addiction problems can leave the hospital at any time (86%), and those who believe that the law did not specify any treatment duration for patients with addiction problems (64%). All these are incorrect statements when the content of the law is examined in detail.

Further analysis of statements differentiating those who agreed from those who did not agree to the law yielded interesting findings. The first is whether the law allows the involuntary admission of addiction patients for treatment or not; those who accepted the law were more likely to reply ‘yes’ to this statement than those who did not (41.2 vs. 13.8%, χ2=14.975, P<0.001). The second is whether the law specifies the treatment duration for the involuntarily admitted addiction patient; those who accepted the law were more likely to agree with this statement than those who did not (48.1 vs. 30.2%, χ2=4.841, P=0.028). Quantitative analysis of their responses showed that they did not really know the correct detention periods.

Knowledge and attitude of patients with substance misuse problems

A large majority of the patients (75.4%) who participated in the study reported that they were currently receiving treatment voluntarily. A significantly higher proportion (90%) of patients were being treated voluntarily in the private sector [Table 5].{Table 5}

Among service users, 63.4% agreed with the law in principle. However, 64% of the participants also believed that patients with addiction problems should receive involuntary treatment for a certain period of time until they become capable of making rational decisions.

The knowledge, attitude, and experience of addiction patients with the law showed differences according to the venue of admission or the place where the service was provided. In our study, we mainly compared the situation in private and public hospitals [Table 5].

Patients from private hospitals were significantly more aware of the existence of the law than those from public hospitals (59 and 43%, respectively). They also believed significantly more that the law applied to addiction (50 and 37%).

The responses of patients who believed that treatment can be initially enforced until the patient becomes capable of making rational decisions (64%) were analyzed further. It was observed that they had fewer admissions than those who disagreed (Mann–Whitney U=21831, P=0.001). They were less frequently involuntarily admitted than those who disagreed (36.4 vs. 56.4%, χ2=18.7, P<0.001) and a higher percentage of them were on voluntary treatment (83.4 vs. 61.1%, χ2= 30.96, P<0.001). The type of hospital offering the service did not differ (χ2=1.04, P=NS) and the mean age did not differ (30.2±7.4 vs. 28.97±7.9 years, t=−1.72, P=NS).

More patients who agreed that the initial enforcement of the treatment was necessary, as compared with those who disagreed, believed that patients with addiction problems can pose a danger to themselves or others before treatment (85 vs. 69%, χ2=18.02, P<0.001).

One of the factors that the patients considered crucial for involuntary admission was linked to how they viewed their illness. The way in which patients viewed addiction and its treatment was related to whether they would accept involuntary treatment or not. In this sample, 67.7% of patients viewed addiction as an illness, 14.3% viewed it as a social problem, 11.5% considered addiction a sin, and another 11.5% considered it as a personal choice (data not included in the table). More patients who agreed to enforcement of treatment viewed addiction as an illness (72 vs. 60%, χ2=6.79, P=0.009). More patients who did not agree to enforcing treatment viewed addiction as a social problem (20 vs. 11%, χ2=8.49, P=0.004). Similarly, 63% of the patients believed that addiction patients require both medical and psychological treatment, 16% believed that the patients require only withdrawal treatment, and 15% believed that treatment is only linked to will (data not included in the table). More patients who agreed that initial enforcement of treatment is necessary believed that addiction patients require both treatments (70 vs. 50%, χ2=20.8, P<0.001). More patients who did not agree about enforced treatment believed that addiction patients require only withdrawal treatment (28 vs. 10%, χ2=29.7, P<0.001).

Knowledge and attitudes of relatives of service users

There is a marginal difference between the relatives and the patients in the degree of knowledge of the New Law [Table 5] and [Table 6]. The majority of relatives (57%) believed that when they are given the chance to read the conditions for compulsory hospital admission (article 13), these provisions should not apply to patients with addiction. Only a small minority (12.7%) believed that the law allows compulsory admission of patients with addiction problems. A large majority (64.6%) of the relatives believed that there was a need to modify some provisions, especially regarding the need for relatives’ consent for admission and allowing involuntary admission of patients. This is similar to a proportion of patients (64%) who stated that they would ‘agree’ to initial involuntary admission, although 63.4% of the patients agreed with the New Law [Table 5].{Table 6}

The most significant findings in the relatives’ questionnaire were those related to the differences between relatives of patients in public sector hospitals and relatives of patients in private sector hospitals. In general, relatives of private patients were more inclined to have a greater role and say in the admission and treatment of their ill relatives [Table 6]. Significantly more private sector relatives (74.1%) were aware of the law compared with 35.8% relatives in public hospitals. However, significantly more public sector than private sector relatives approved of the provisions of article 13 (48%, 29.6%) and believed that compulsory admission of patients with addiction is sanctioned by the law (19.8%, 7.4%).

[Table 7] presents the actual difficulties encountered in receiving the service before and after the law according to relatives. It is very clear that several problems continue to persist in clinical facilities even after the introduction of the law. Refusal of involuntary admission increased significantly in both the public and the private sectors, and it was more pronounced in the latter. [Table 7] also shows that, among the relatives, there was a degree of confusion and lack of clarity on where to seek help for the patients and how the service works after the introduction of the law. It also seems that the problems in the private sector facilities are worse as shown in [Table 7]; relatives reported higher numbers of early discharges after the introduction of the law, and refusal of admission of even voluntary patients. For unclear reasons, both groups of relatives agreed that treatment after enforcement of the law is less effective.{Table 7}


This study confirms that there are significant doubts in the minds of service users and service providers about the status of substance misuse in the Law 71 for the Care of the Mentally Ill Patient (2009), such as gaps in knowledge, misunderstandings, and a generally reserved and even suspicious attitude toward the New Law. Although more than 90% of the sample of service providers in the field of substance abuse were aware of the existence of new mental health legislation in Egypt, more than 50% of patients of substance abuse and their relatives were not aware of it. About two-thirds of patients did agree with the New Law, whereas more than two-thirds of the service providers did not. About 80% of service providers and 87% of relatives believed that the 2009 legislation does not allow involuntary admission of patients with substance use disorders for treatment in mental health institutions.

This study deals with a rather major problem in Egyptian psychiatric practice. Because of the significance of the problem and the peculiarity of the situation, a specially designed tool has been used in the study, after being examined for construct validity. On reviewing the literature, no comparable instruments were found. This complicates the assessment of the other forms of validity and reliability. Trials to overcome this problem were considered during preparation by developing different sections on well-known references such as the legal aspect of the addiction severity index (McLellan et al., 1980) and the questionnaire used in the National survey of Addiction (Hamdy et al., 2011), and the Egyptian law of mental health (2009).

Substance use disorders are not specifically mentioned in any of the articles of the Egyptian Mental Health Law 71/2009. The spectrum of mental disorders covered by the law is mentioned in the introduction to cover all mental disorders described in the WHO classification. Involuntary admission of mentally ill patients is specified in article 13 and is based on the concept of ‘dangerousness’ of the mentally ill patient and severe deterioration in mental condition. The Executive Memorandum (2010) states that substance dependence is not considered a sufficiently good reason for compulsory admission, and does not mention any criteria to clarify the danger or major deterioration in relation to substance misuse. This led to ambiguity among service providers, and led the Egyptian Psychiatric Association (EPA) to recommend its removal. The amendment has been accepted (Executive Memorandum, 2011).

A person with a substance use disorder, therefore, has to fulfill the requirements of the commitment statute, whether he or she is a danger to self or others or whether there is a severe deterioration in his or her condition. About 43% of patients’ relatives and 60% of the psychiatrists in this study agreed that these emergency conditions apply to patients with substance abuse problems.

Seventy percent of patients agreed that patients with substance abuse problems may not be able to make decisions rationally before treatment and 80% of the patients believed that substance abuse patients may be dangerous to themselves or others. This is in agreement with the findings that opioid-dependent individuals have been found to have 13 times higher annual mortality than that of their peers. This increased mortality is primarily because of overdoses, violence, suicide, and smoking-related and alcohol-related causes (Hulse et al., 1999; Vlahov et al., 2004).

Despite this high agreement among service providers, patients, and their relatives about considering the admission of patients with substance abuse as an emergency condition, the vast majority (about 80% of service providers and 87% of patients’ relatives) believed that the law does not allow compulsory admission under these conditions. This can be attributed to the low percentage of service providers who had received training about the law (45%), in addition to the low awareness of the patients’ relatives, as only 42% of them believed that the law applies to addiction. Moreover, members of the mental health inspection teams, despite being trained, tended to consider patients with substance abuse problems as having mainly ‘behavioral problems’ and allowed their voluntary discharge. This attitude of the inspection teams resulted in more ambiguous and defensive responses from the service providers such that scientific practices were ignored. A higher percentage of inaccuracy about the law regarding commitment in substance use disorders was found in a survey conducted in the USA involving about 739 psychiatrist members of APA. The survey reported an erroneous concept of 83.5% for alcohol addiction, 78.8% for addiction relapse, and 76.4% for drug addiction (Brooks, 2007).

Sixty-four percent of patients in this sample agreed that involuntary treatment may be required for a certain period of time until they can make rational decisions and 68.8% of the patients’ relatives believed that the law needs to be modified to allow involuntary admission. This could be related to practices before law enforcement, wherein 43% of the sample had been previously admitted involuntarily. In addition, families reported facing greater difficulties in admitting their patients, and stated that their inability to admit the patients involuntarily has increased from 34.8 to 50.5% in the hospitals of the Ministry of Health, and from 14.1 to 30.8% in the private sector, since the enforcement of the law. This indicates a significantly higher percentage of refusals of involuntary admissions from both public and private hospitals. Families burdened by the consequences of a chronic relapsing disorder tended to seek nonspecialist treatment for their relatives (35% in this study). If families seek treatment outside the medical field, then it is all the more important that medical treatment be facilitated rather than hindered.

In contrast, Brooks (2007) survey showed that only 22% of the participating psychiatrists supported admission for alcohol abuse and 22.9% for admission for abuse of other substances. However, the author claimed that respondents might have favored involuntary treatment more if the questionnaire had classified substance abuse as a type of mental illness, with other conditions (such as dangerousness) necessary for commitment.

There is a clear will amongst service users and their relatives requesting an involuntary admission possibility for patients with substance abuse. In Egypt, this is particularly relevant because the current criminal law (Narcotic Law, 1989) does not actually apply to various schemes for patients of addiction. In other words, although the criminal law in Egypt allows for treatment of patients with addiction instead of incarceration, this is rarely used in light of the poor communication between the healthcare system and the criminal justice system. In the USA, and more recently in some European countries, for example UK, drug treatment courts have a provision for long-term court-supervised treatment of offenders, usually nonviolent offenses, with drug problems. In many jurisdictions, drug courts are preferred in dealing with drug-involved or alcohol-involved offenders to facilitate community-based treatment and related clinical interventions (Hora and Schma, 2009; Rossman et al., 2011).

This debate about free will and motivation is evident in the management of substance use disorders. Some may rely on traditional liberal notions of individual freedom, whereas others may argue that patients do not benefit as much from involuntary treatment (Luchins et al., 2004; Clark and Bizzell, 2009). Most authors who have addressed this subject agree that patients admitted compulsorily generally enter treatment with greater resistance to therapy and less motivation to change than those who begin treatment voluntarily (Miller and Rollnick, 1991; Rooney, 1992). However, Leukefeld and Tims (1988) and Hampton et al. (2011) addressed the importance of both internal and external motivation in the treatment process and relapse. The role of external pressure, from their viewpoint, is to influence a person to seek treatment. A recent study in the USA found that less than 10% of patients with substance use disorders seek treatment and most of them do so because of external coercive influences (Brauser, 2011).

Outcome research reports have shown that patients admitted compulsorily did better than voluntary patients (Burke and Gregoire, 2007; Perron and Bright, 2008); others, for example Gerstein et al. (1997) have reported that voluntary clients fared better. The majority, however, have found similar beneficial outcomes for both groups (Allan, 1987; Simpson and Friend, 1988; Brizer et al., 1990; Brecht et al., 1993; Joe et al., 1999). Snyder and Andersons (2009) recommended that implementation of a more externally constraining system that does not rely on an individual’s fluctuating motivational state would represent a less costly and more efficient process.

However, Sullivan et al. (2008) concluded that informal psychosocial pressures from spouses, family, and employers may have substantially more influence over decisions to enter treatment than legal pressures.

This ambiguity seems to, at least partially, arise from two concepts: first, human rights and rights-driven values regarding the right to choose, which plays a strong role in shaping any decision or vision, and second (as a consequence), addiction is viewed more as a lifestyle choice and less as an illness.

A professional guided by the basic code of ethics of maximizing benefits (beneficence) and reducing harm (nonmaleficence) would find it difficult to reconcile these basic concepts with the aforementioned concepts without resolving two issues.

First, how can the ‘choice’ to be dominated by a substance or alcohol and defy treatment be in the best interest of the person and hence endorsed by the professional?

Second, how can a person addicted to a substance or alcohol, that is, by definition be compelled to take them to be able to function, be evaluated as having volition to choose freely? How can a person with such a condition, which is known to impair the ability to assess existing options and the perception of reality, be considered capable of giving informed consent or taking a decision involving choosing between alternatives?

Another factor is the cultural context; euthanasia has been accepted by some western cultures most probably out of respect for freedom of choice and quality of life, provided that the patient has demonstrated intact volition and the capacity to give informed consent. However, this concept is not accepted in our culture. Similarly, at least for the time being, families in our culture assume responsibility for their members, both minors and seniors, unlike in most western cultures, where it is the responsibility of the social services. As such, families, to some extent, have responsibility toward their members. Admission of drug addicts to treatment has been carried out by families coercing their relatives into treatment. This role could be seen as corresponding to that of the social services abroad, that is, part of the duty not coercion. Measures and guidelines based on best practice are needed to prevent abuse of this family role instead of eradicating it.


Obtaining the view of service providers, users, and patients’ family in the field of substance abuse on the new legislation for mental health is important as it helps to identify areas of controversy and to encourage discussion, paving the way toward relevant suggestions for modifications of the law, if needed.Considering the application of the new mental health law (71/2009) for substance use disorders, ambiguity exists in the regulations related to compulsory admission for treatment as well as the duration of treatment and discharge.


There is a need to:

Make relevant modifications in the 2009 Egyptian Mental Health Law considering regulations for treatment of patients with substance use disorders. Clarity and cultural sensitivity are essential.

Consider implementation of special sections for involuntary admission on the basis of guideline criteria of best practice.

Direct more training efforts at young psychiatrists as well as therapeutic team members on the regulations of mental health law as well as for effective motivational interventions to reduce resistance to treatment.

Increase public awareness: regarding disease model of addiction, mental health, and criminal law regulating admissions for treatment and how to access available services.

Involve existing governmental specialized committees to study the needs of families who have members with severe addiction problems according to their request to decide the possible need for mandatory treatment.

Modify and actualize the criminal law on narcotics; referral from courts to treatment centers requires consideration, interorganizational cooperation between the legal and the medical system, and perhaps consider the successful Drug Court Model.

Free optional discontinuation of therapeutic trials must be restricted to minimum levels as a means of prevention of relapse. This could be achieved through proper professional decisions of independent governmental specialized committees such as the National Mental Health Commission.


The sample was recruited from two governorates, Cairo and Alexandria, and this might not be representative of the whole of Egypt, with a bias that might arise from the level of awareness, which may be higher when compared for example with upper Egypt.

Some of the mental health professionals were not represented sufficiently (for example nursing staff represented 8% of the sample).

Most of the service providers were from the public sector, whose experience may be different from those working in university hospitals and NGOs.[24]


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