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www.thelancet.com Published online October 17, 2011 DOI:10.1016/S0140-6736(11)60941-0 1

A global scope for global healthincluding mental health

Unprecedented opportunities to promote excellence

and equity in health-care delivery for the worlds most

underserved populations are upon us. Successful

programmes to reduce the transmission of and mortality

from infectious diseases have invigorated discourse about

the human right to health, and have resulted in viable

platforms for comprehensive health programmes that

provide care to millions of people facing both poverty

and chronic disease.1 Indeed, the past decade has seen

the introduction of the first such platforms designed to

treat incurable disorders, from AIDS to diabetes. Rapidscientific advances and health-system improvements

that help us to understand and redress the biosocial roots

of poor health and to develop diagnostics, therapeutics,

and the technology and infrastructure to disseminate

and implement them, promise to extend benefits to care

delivery in the realm of non-communicable diseases.

However, delivery of mental health services in low-

resource settings lags unacceptably and unjustly far

behind that of other services. Neuropsychiatric disorders

comprise a substantial share of disease-related burden

and disabilityapproaching 14%, with depressionthe leading global cause of disabilitybut receive a

disproportionately low resource allocation: the average

across countries is under 4% of overall health-care

budgets.2,3 Resources for mental health research are also

scarce and knowledge gaps persist.4 Alongside a shortfall

in trained mental health professionals, these deficits

are the backdrop to a disconcerting treatment gap for

neuropsychiatric disorders in low-income countries,

with over 75% of patients untreated.5,6 Even these dismal

metrics do not fully convey the unconscionable neglect,

social discrimination, and frequent abuse endured by

the mentally ill,7 a situation aptly described as a failure

of humanity.8

Although uncontested, neither inventories of need,9

nor the pragmatic refrain of no health without mental

health by Prince and colleagues,2 which opened The

Lancets 2007 Series on global mental health, have

gained suffi cient purchase. How the message could

be amplified further to transform a narrative of global

neglect is diffi cult to imagine.

Additional structural (largely economic) and cultural

obstacles beset efforts to provide more effective and

accessible care for mental disorders in low-resource

settings.9 However, barriers that prevent patients from

seeking help and impede care for mental disorders

eg, functional impairment, social stigma, and low health

literacy in patients and caregivershave been encoun-

tered and overcome for other disorders, as the success

of the movement to confront HIV/AIDS shows. Notably,

this triumph for global health equity was achieved when

prevention was integrated with high-quality care through

the creation of new financing mechanisms.10,11 Although

much remains to be done, the successful implementation

of programmes in poorer parts of the world should act asa model for care delivery in other health-care domains,

including mental health, as the coalition Movement for

Global Mental Health has declared.12

Strategies to close the mental health resource

gap in low-income regions are in sight, a research

agenda is being set, and new protocols are ready for

implementation.13,14 In 2010, WHO released its much-

anticipated mental health Gap Action Programme

Intervention Guide to support the implementation of

treatment for mental, neurological, and substance-use

disorders in primary-care health settings.15

Thoughtfullyconceived basic treatment packages for common mental

health disorders could improve delivery of key services

at low expenditure in countries of low and middle

income.1618 Straightforward treatment algorithms and

innovative task-shifting mechanismswell established

for other conditionsrender affordable and effective

mental health care within reach, and with it potentially

vast collateral health and social benefits.19

However, an argument based solely on cost-

effectiveness is unwise if it promotes only one narrow

sector of the health agenda at the expense of others.

Investments are needed that build on, rather than

compete with, the newly created platforms to prevent

and treat other chronic illnesses. The broad health

benefits of programmes focused on HIV/AIDS prevention

and care show that good mental health care would not

dilute primary health care, but could strengthen it.10,11 A

unified call for integrated and comprehensive models

of health-care delivery, inclusive of non-communicable

diseases and mental disorders, would be compelling.

The UN General Assembly High-level Meeting on

Non-communicable diseases in September was only

the second Special Session convened about a health-

Published Online

October 17, 2011

DOI:10.1016/S0140-6736(11)60941-0

See Online/Series

DOI:10.1016/S0140-

6736(11)60754-X,

DOI:10.1016/S0140-

6736(11)60827-1,

DOI:10.1016/S0140-

6736(11)61094-5,

DOI:10.1016/S0140-

6736(11)60891-X,

DOI:10.1016/S0140-

6736(11)61093-3, and

DOI:10.1016/S0140-

6736(11)61458-X

BasicNeeds

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Comment

2 www.thelancet.com Published online October 17, 2011 DOI:10.1016/S0140-6736(11)60941-0

related issue.20 Preceding optimism was warranted, but

if the collective ambition of global-health advocates,scientists, and practitioners is to promote social and

economic rights and equitable access to evidence-

based health services for all, we must also construe and

promote global health as encompassing a global scope

of health domains.

We join the call for the inclusion of mental health in

a comprehensive health agenda for the worlds poorest

populations.21 The pragmatic and moral imperatives

are self-evident: without mental health care, there is no

justice. The methods are in hand, the advocates have been

mobilised, and the message should be unified action.

*Giuseppe Raviola, Anne E Becker, Paul FarmerProgram in Global Mental Health and Social Change, Department

of Global Health and Social Medicine, Harvard Medical School,

Boston, MA 02115, USA

giuseppe_raviola@hms.harvard.edu

We declare that we have no conflicts of interest.

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2 Prince M, Patel V, Saxena S, et al. No health without mental health.Lancet 2007; 370: 85977.

3 Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mentalhealth: scarcity, inequity, a nd ineffi ciency.Lancet 2007; 370: 87889.

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15 WHO. mhGAP intervention guide for mental, neurological and substanceuse disorders in non-specialized health settings: mental health Gap ActionProgramme (mhGAP). Geneva: World Health Organization, 2010.

16 Patel V, Simon G, Chowdhary N, Kaaya S, Araya R. Packages of care fordepression in low- and middle-income countries. PLoS Med 2009;6: e1000159.

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