mental health for sustainable development€¦ · yet mental health is generally given a very low...

1Mental Health for Sustainable Development

All-Party Parliamentary Group on Global Health All-Party Parliamentary Group on Mental Health

Mental Health forSustainable Development

Dr Mary De Silva & Jonty Roland, on behalf of the Global Health and Mental Health All-Party Parliamentary Groups

2 Mental Health for Sustainable Development

Abbreviations

APPG All-PartyParliamentaryGroup

BME BlackandEthnicMinority

DALY DisabilityAdjustedLifeYear

DFID DepartmentforInternationalDevelopment

EMERALD Emergingmentalhealthsystemsinlow-andmiddle-incomecountries

MDG MillenniumDevelopmentGoal

mhGAP MentalHealthGapActionProgramme

NGO Non-GovernmentalOrganisation

NHS NationalHealthService

PCAF PeterC.AldermanFoundation

PRIME PRogrammeforImprovingMentalhealthcarE

THET TropicalHealthandEducationTrust

SDGs SustainableDevelopmentGoals

WHO WorldHealthOrganization

YLD YearLivedwithDisability

ThisisnotanofficialpublicationoftheHouseofCommonsortheHouseofLords.All-PartyGroupsareinformalgroupsofmemberswithacommoninterestinparticularissues.ThisreportisfundedbythesponsorsoftheAll-PartyParliamentaryGrouponGlobalHealth

Alloftheprojectsandorganisationshighlightedinthisreportandonthemaponpage20areprofiledontheMentalHealthInnovationNetworkinagrowingdatabasewhichcurrentlyhostsmorethan85innovativeexamplesofbestpracticeinmentalhealthpromotion,preventionandtreatmentfromaroundtheworld.

http://www.appg-globalhealth.org.uk/

http://www.mhinnovation.net/innovation


Contents

Preface 4

Executivesummary 5

Recommendations 7

1.Whymentalhealthmattersglobally 8

2.Whatsolutionsexist? 14

Improvingmentalhealthglobally 20

3.TheUK’scurrentcontributiontoglobalmentalhealth 22

4.Doingmoreandactingdifferently 24

References 27


Thesimplemessageofthisreportisthatprogressindevelopmentwillnotbemadewithoutimprovementsinmentalhealth.

Thereasonsareequallystraightforward.Mentalillnessescausemoredisabilitythananyotherhealthcondition;bringenormouspainandsufferingtoindividualsandtheirfamiliesandcommunities;andcanleadtoearlydeath,humanrightsabusesanddamagetotheeconomy.Improvingmentalhealthisthereforeavitalpartofasuccessfuldevelopmentprogramme.

Yetmentalhealthisgenerallygivenaverylowpriority–andoftenneglectedaltogether-inbothnationalandinternationalpolicy.

TheUKgovernmentcangiveapowerfulleadtocorrectthisthroughDFIDanditsworkwithotherinternationalbodies;however,italsoneedstodevelopitsownpoliciesandpracticestogivementalhealthgreaterpriorityand,crucially,paritywithphysicalhealth.Mentalhealthneedstomovefrombeinganafterthoughttoanessentialpartofsocialpolicy,healthsystemstrengtheningandhealthimprovement.

ChangeisalsoneededintheUK’svibrantvoluntarysectorwhich,withafewnotableexceptions,doeslittleinthisarea.Moreover,thenegotiationsontheforthcomingSustainableDevelopmentGoalspresenttheopportunityforrealchange.Asthereportsays,weknowwhatneedstobedone.Whatisneedednowisachangeinmindsetaswellasinpolicyandpractice.

Wewouldliketothankallthosewhocontributedideas,evidenceandcasestudies.Inparticular,wewouldliketothankthereport’stwoauthors,DrMaryDeSilvaandJontyRoland,aswellastheteamwhichsupportedthemconsistingofVanessaHalipi,LisaTownsend,GraceRyan,LucyLee,CatherineRushworthandWillBurch.

Lord Crisp APPG on Global Health

Meg Hillier MP APPG on Global Health

James Morris MP APPG Mental Health


Preface

5Mental Health for Sustainable Development 5

The scale of the problem is better understood than ever. Cost-effective solutions for addressing it exist. It is becoming increasingly apparent that successful development will not take place without addressing mental health. The time is right to consider what the UK is currently doing to improve mental health globally and whether UK expertise and resources could be more effectively used to meet this challenge.

Mentalhealthproblemsaccountforalmost13percentoftheworld’stotaldiseaseburden,affectupto10percentofpeopleacrossthelifecourseatanyonetime,andmakeupoveraquarteroftheyearspeoplelivewithdisabilityglobally.1ThiscoststheworldsomeUS$2.5trillionperyear,2yettheamountinvestedintreatingmentalhealthproblemsisbarelyafractionofthis–lessthantwopercentofthehealthspendinginmostlowandlower-middleincomecountries.3

Depression,substanceabuse,schizophrenia,learningdisabilitiesandothercommonconditionsarenotsimply‘Westernissues’.Almostthreequartersofpeoplewithmentalhealthproblemsliveinlowandmiddleincomecountries4andreceivelittleornoevidence-basedtreatment.Thisreportsetsoutthreeimportantargumentswhymentalhealthmattersgloballyandwhydevelopmentactivitywillnotbetrulysuccessfulwithouttacklingmentalhealthissues:

The health case Peoplewithmentalhealthproblemshaveshorterlivesandworsehealththanothers.Thisisduetosuicide,mentalhealthproblemsworseningthecourseandinterferingwithappropriatecareandself-managementofphysicalhealthproblems,andpoorertreatmentofthoseproblemsbythehealthsystem

The social and economic case Mentalhealthproblemsareabrakeondevelopmentastheycause(andarecausedby)poverty.Thisfuelssocialfailuresincludingpoorparentingandschoolfailure,domesticviolence,andtoxicstress,preventingpeoplewithproblemsandtheirfamiliesfromearningaliving

The human rights case Peoplewithmentalhealthproblemsareoftensubjectedtoseriousabuse,suchaschaining,andinmanycountriesaredeniedfundamentalhumanrightsandprotectionsthroughdiscriminatorylaws.

Despitestrongeconomic,social,humanitarianandepidemiologicalargumentsfortacklingmentalhealthinlowandmiddleincomecounties,mentalhealthisdisproportionatelypoorlyfundedaroundtheworld.Inlowincomecountries,asfewasonein50peoplewithaseriousmentalhealthproblemeverreceivestreatment.

“��Mental�illnesses�are�killer�diseases.�They�need�to�take�their�place�among�the�other�killer�diseases�for�investment�and�priority”

Graham Thornicroft, Professor of Community Psychiatry, King’s College London

Executive summary


Fortunately,agrowingbodyofresearchisshowingthat–eveninthepoorestcountries–cost-effectivesolutionstothisglobalchallengeexist.Theseinclude:

Improvingsocialandeconomicenvironmentsaspartofsustainabledevelopmentsothatmentalhealthproblemsarelesslikelytooccur Integratingmentalhealthintogenericprimaryhealthcare Usingtrainedandsupervisedcommunityandnon-specialisthealthworkers

toprovideculturallyappropriatecareandtreatmentinthecommunity Harnessingtechnologytobuildworkforcecapacity,connectpeople

withspecialisthelp,andincreaseaccesstoself-help Empoweringpeoplewithmentalhealthproblemstosupport

andadvocateforthemselvesandforeachother Improvingthephysicalhealthcareofpeoplewithmentalhealthproblems Advocatingforgreaterrightsandrepresentationforpeoplewithmentalhealthproblems

Thisreportcontainspracticalexamplesofalloftheseapproaches,manyofwhichholdlessonsforhighlydevelopedhealthsystemsaswell–suchashowtointegratementalhealthintoexistingphysicalhealthservicesandhowtoadaptmentalhealthinterventionstoworkacrossdifferentcultures.

Thesesolutionsarebeginningtoraiseglobalmentalhealthuptheinternationalagenda.Ayearago,memberstatesoftheWorldHealthOrganization(WHO)unanimouslysupportedtheadoptionoftheComprehensiveMentalHealthActionPlan2013–2020.Thisrecognisestheimportanceofmentalhealthasaglobalhealthpriority,andcommitstofourkeyobjectivesby2020:

Strengtheneffectiveleadershipandgovernanceformentalhealth Providecomprehensive,integratedandresponsivementalhealth

andsocialcareservicesincommunity-basedsettings Implementstrategiesforpromotionandpreventioninmentalhealth Strengtheninformationsystems,evidenceandresearchformentalhealth

TheUKwasanimportantsupporterofthisglobalagreementandhasmuchtocontributebutasyetdoesnothaveaclearstrategyforwhatitsroleinachievingtheActionPlanwillbe.

AlthoughtheBritishGovernmentandotherinstitutionsaredoingmorethanmosttoimprovementalhealthinlowandmiddleincomecountries,theseinitiativesarefewinnumberandareoftenisolated.Thisreportgivesanumberofpracticalrecommendationsfor‘doingmore’and‘doingdifferently’.

“��We�have�such�good�cost-effective�interventions.�Treatments�for�mental�disorders�are�as�cost-effective�as�those�for�other�chronic�diseases�like�diabetes”

Vikram Patel, Wellcome Trust Senior Research Fellow, London School of Hygiene & Tropical Medicine

“��The�challenge�is�we�have�in�the�order�of�a�billion�people�on�the�planet�who�will�have�a�mental�health�problem�in�their�lifetime�and�not�get�evidence-based�care�for�it.�A�response�to�that�sort�of�problem�needs�action�at�a�global�level.�It�needs�the�sorts�of�global�structures�we’ve�created�for�malaria�and�HIV�to�be�created�for�mental�health�as�well”

Gary Belkin, Executive Deputy Commissioner, New York City Department of Health and Mental Hygiene


Recommendation 1

TheDepartmentforInternationalDevelopment(DFID)to‘integrate’,‘evaluate’and‘replicate’globalmentalhealthinitsprogrammesinordertosupportcountriestoimplementtheWHOActionPlan:

‘Integrate’byconductinga‘mentalhealthinallpolicies’reviewtostrategicallyconsideritsroleinachievingtheWHOMentalHealthActionPlanobjectives ‘Evaluate’byincorporatingmentalhealthimpactmetricsintoitsexistingprogrammes ‘Replicate’bycommittingtoprogrammefundingtoscaleupmentalhealth

projectsthatprovesuccessfulaspartofDFID-fundedresearch

Recommendation 2

NGOsandothersworkingininternationaldevelopmentshouldsupportstafftounderstandtheneedsandcapacitiesofpeoplewithmentalhealthproblems,encouragetheinclusionofpeoplewithmentaldisordersintheirgeneraldevelopmentprogrammes,setupnewmentalhealthspecificprogrammes,andmeasuretheimpactoftheirprogrammesonmentalhealth

Recommendation 3

Professionalbodiesandmentalhealthproviders,withthesupportofgovernment,shouldestablishandexpandtrainingandresearchpartnershipswithlowandmiddleincomecountries–seekingtoteachandtolearnaboutprofessionalskills,tacklingdiscriminationandpolicyreform

Recommendation 4

TheUKshouldlobbyfortheinclusionofthefollowingmentalhealthtargetwithintheHealth Goalin the SustainableDevelopmentGoals

“Theprovisionofmentalandphysicalhealthandsocialcareservicesforpeoplewithmentaldisorders,inparitywithresourcesforservicesaddressingphysicalhealthandworkingtowardsuniversalcoverage”

Recommendations


There are powerful reasons why improving mental health in low and middle income countries should be a key global concern. Mental disorders are responsible for a significant proportion of the disease burden in developing countries. They impede social and economic development. They impair community fabric and impair crucial collective needs such as parenting, child development, and school success.5 They are also associated with some of the world’s most pervasive human rights abuses. Despite a compelling case, mental health is disproportionately poorly funded around the world - especially in low and middle income countries.

Mentalhealthisanindispensablecomponentofhealth,definedbytheWHOas“astateofwell-beinginwhicheveryindividualrealizeshisorherownpotential,cancopewiththenormalstressesoflife,canworkproductivelyandfruitfully,andisabletomakeacontributiontoherorhiscommunity.”6‘Mentalhealthproblems’isatermthatreferstoasetofmedicalconditionsthataffectaperson’sthinking,feeling,mood,abilitytorelatetoothers,anddailyfunctioning.Thisincludesawiderangeofconditionssuchasdepressionandanxiety,drugandalcoholabuse,andschizophrenia.

Inthisreport,andinlinewithguidancefromtheWHO,theneurologicalconditionsdementiaandepilepsyarealsoincluded,asinlowandmiddleincomecountriestheirtreatmentissimilartomentalhealthproblemssuchasschizophrenia.7Table1presentsdefinitionsforthementalhealthandneurologicalproblemsincludedinthisreport,allofwhichcauseasignificantdiseaseburdeninlowandmiddleincomecountries.

Therearethreecompellingargumentswhyimprovingmentalhealthshouldbeconsideredavitalcomponentofglobalhealthanddevelopment:thehealthcase,thehumanrightscaseandthesocialeconomiccase.

The health case: mental health problems cause more disability than any other health problem, as well as high levels of premature mortality

Mentalhealthproblemsareextremelycommoninallcountriesoftheworld.Atanypointintime,morethanonein10peoplehaveamentalhealthproblem:1nearlythreequartersofthesepeopleliveinlowandmiddleincomecountries.4

Mentalhealthproblemsarethemostdisablingofallhealthconditions,contributingnearlyonequarterofallYearsLivedwithDisability(YLDs)globally(Figure1).Importantly,thoughthereisvariabilitybetweencountriesintheburdenofsomedisorders(particularlyalcoholuse),mostdonotdiffersignificantlyfromtheglobalaverage.Ratesofmentaldisordersinlowandmiddleincomecountriesareverysimilartothoseinhighincomecountries.1Theburdenisgreatestinpeopleaged10-29years,reflectingtheearlyageofonsetofmanysubstanceuseandcommonmentaldisorders.1ThisisparticularlyimportantforregionslikeAfrica,whereupto40percentofthepopulationarechildren.8

1. Why mental health matters globally


Table1:Theglobalburdenofmental,neurological,andsubstanceuseanddisorders

Mentalandsubstanceusedisorders:7.4percentofglobaldiseaseburden(DALYs*)

Developmentaldisorders Agroupofconditionswhichdevelopfrombirthonwards,characterisedbyimpairmentsinintellectual,movement,sensory,social,orcommunicationabilities(e.g.autism,intellectualdisabilityandcerebralpalsy)

Childbehaviouraldisorders

Agroupofconditionscharacterizedbyimpairmentsofattentionanddisruptivebehaviour(e.g.attentiondeficithyperactivitydisorderandconductdisorder)

Drugandalcoholuseproblems

Agroupofconditionscharacterisedbyregularuseofdrugsandalcoholtothelevelofcausingharmtotheperson’shealthandsocial/personalrelationships

Commonmentaldisorders

Agroupofconditionsincludingdepressivedisorders(lowmood,lossofinterestandenjoyment,andfatigue)andanxietydisorders(excessiveworrying,tensionandfear,andphysicalsymptomssuchaspalpitations,headachesandsleepdisturbances)

Psychosis Agroupofconditionscharacterizedbydistortionsofthinkingandperception(e.g.hallucinationsanddelusions),behaviouralabnormalitiesandemotionaldisturbance,includingschizophrenia

Self-harmandsuicide:1.5percentofglobaldiseaseburden(DALYs)

Self-harmandsuicide Intentionalself-inflictedpoisoningorinjurywhichmayleadtodeath.

DementiaandEpilepsy:1.15percentofglobaldiseaseburden(DALYs)

Dementia Organicbraindiseasescharacterizedbyaprogressivedeteriorationinmentalfunctions,suchasmemoryandorientation,leadingtobehaviouralproblemsandlossoftheabilitytocareforoneselfandultimatelydeath

Epilepsy Neurologicalconditionwherethereisatendencytohaveseizuresthatstartinthebrain.Repeatedseizureswithouttreatmentcanresultinpermanentbraindamage

* Disability Adjusted Life Years: A measure of the number of years lost due to death, disability and ill health. Source: 2010 Global Burden of Disease estimates9


0 5 10 15 20 25

Cardiovascular and circulatory diseases

Diarrhea, lower respiratory infections, meningitis and other common infectious

diseases

Neonatal disorders

Cancers

Mental health problems

Figure1:Topfivecontributorstotheglobalhealthburden(DALYsandYLDs)

Reproduced from Patel V, Saxena S, De Silva M, & Samele C. Transforming Lives, Enhancing Communities: Innovations in Mental Health (2013) Report for the World Innovation Summit for Health10

Source: Global Burden of Disease study 20101

Theheavyhealthburdenofmentalhealthproblemsisalsotheresultoftheirdamagingimpactonphysicalhealth.Inhighincomecountries,menwithseverementalhealthproblemsdieupto20yearsandwomen15yearsearlierthanpeoplewithoutmentalhealthproblems.11Inthepoorestcountriesthislifeexpectancygapislesswelldocumented,butislikelytobemuchwider.12Thisexcessmortalityisduetosuicide,unhealthylifestyles(suchashighsmokingrates)andpoorerphysicalhealthcareforpeoplewithmentalhealthproblems.11,13Globally,nearly1millionpeopletaketheirownliveseveryyear,14nearlydoublethosewhoarekilledasaresultofconflictorcriminalviolence.15Betweenhalfandthree-quartersofsuicidescouldbeavertedifmentalhealthproblemsweretreated.16Thisexcessandavoidablemortalityhasbeendescribedasaformof“lethaldiscrimination”.17Inaddition,mentalhealthproblemscorrodesociallife,lifelongdevelopment,andoverallhealth.Forexample,theeffectsofmaternaldepressiononchildren,andexposureinearlylifetotoxicstress,castsalongshadowonlifetimementalandphysicalhealth,andsocialsuccess.18

% of total Years Lived with Disability (YLDs)

% of total Disability Adjusted Life Years (DALYs)


The social and economic case: mental health problems impose a tremendous economic and social cost to society that places a brake on development efforts

Thecostsofmentalhealthproblemsarestaggering.TheWorldEconomicForumestimatesthattheglobalcostofmentalhealthproblemswasUS$2.5trillionin2010,andwillrisetoUS$6.0trillionby2030.2Aroundtwo-thirdsofthesesocietalcostsareduetoreducedeconomicproductivity,highratesofunemployment,andunder-performanceatwork.2Attheindividuallevel,thesecostscomefromlossofproductivityfromtheaffectedpersonandtheircaregivers,andfromoftencatastrophicoutofpocketexpenditureonhealthservices.19

Povertyandmentalhealthproblemsareintimatelyrelatedtooneother,withthoselivinginpovertymorelikelytodevelopmentalhealthproblems,andmentalhealthproblemsleadingtoadownwardspiralofeconomicdisenfranchisement.2,20Thisisparticularlytrueinpoorercountries,wheretheabsenceofawelfaresafetynetandlackofaccesstoeffectivetreatmentsacceleratethecycleofdisadvantage.Breakingthisviciouscyclebytacklingbothcausesandconsequencesofmentalhealthproblemsiskeytoensuringsustainabledevelopmentinallregionsoftheworld.

The human rights case: people with mental health problems are subject to some of the world’s worst human rights abuses

Peoplewithmentalhealthproblemsfrequentlyexperiencestigmaanddiscriminationwhichactasabarriertoparticipationinsocialandeconomicactivitiesandmaypreventthemseekingtreatment.21Ratesofbothanticipatedandexperienceddiscriminationareconsistentlyhighacrosscountriesfrommanyregionsoftheworld,andactasabarriertoseekinghelp,receivingsuccessfultreatment,andsocialandvocationalintegration.21,22Inmanycountriesthecivilandpoliticalrightsofpeoplewithmentalhealthproblemsareviolated,suchasinNepalwherementalillnessislegalgroundsfordivorceresultinginmanywomenbeingabandonedonthestreetsbytheirhusbands(seemaponpage20),orinLithuaniawheresomepeoplewithlongtermmentalhealthproblemsareunabletoowntheirownhome.23AreviewofmentalhealthlegislationinCommonwealthcountriesfoundthatmostlegislationwasoutdated,wasnotcompliantwiththeConventionontheRightsofPersonswithDisabilities,usedstigmatisingtermssuchas‘lunatic’,anddidnotinvolvepeoplewithmentaldisordersinthedevelopmentandimplementationofthelegislation.24

Asaresultofoutdatedlawsleadingtodiscrimination,stigma,andpooraccesstoservices,peoplewithmentalhealthproblemsaremorelikelythanotherstoexperiencesocialexclusion,violentvictimizationandhumanrightsabuse.25Thisincludesbeingchainedtotheirbedsorkeptinisolationinpsychiatricinstitutions,beingincarceratedinprisons,beingchainedandcagedinsmallcellsinthecommunityandbeingabusedbytraditionalhealingpractices.25,26Evenwherepsychiatricwardsareincludedingeneralhospitalstheyaregenerallyinmuchworseconditionthanthegeneralmedicalandsurgicalwards.InIndonesiaforexample,theMinistryofHealthestimatesthat18,800peoplewithmentalhealthproblemsarecurrentlyshackledinthecommunity,apracticesocommonithasitsownname,‘pasung’(seemaponpage20).27Thesehumanrightsabuseshavebeendescribedas“afailureofhumanity”.25

“��When�countries�are�setting�out�their�health�agendas,�very�rarely�are�mental�health�experts�involved,�and�consequently�very�rarely�are�governments�finding�that�mental�health�is�a�priority”

Ken Grant, Director, HLSP Institute


Global under-investment in mental health

Lackofpublicawareness,highlevelsofstigmaandinadequatepoliticalattentionhaveledtoachronicunderinvestmentinmentalhealthcare.Middleincomecountriesallocatelessthantwopercentoftheiralreadysmallhealthbudgetstothetreatmentandpreventionofmentalhealthproblems,andlowincomecountrieslessthanhalfofonepercent3(Figure2).Morethanhalftheworld’spopulationliveinacountrywithfewerthanonepsychiatristper200,000people,3withanestimatedshortageof1.18millionmentalhealthworkersinlowandmiddleincomecountries.28Mostofthesescarceresourcesareallocatedtoasmallnumberofpsychiatrichospitalslocatedinmajorcities,leavingthevastmajorityofthepopulationwithnoaccesstoanymentalhealthcare.

Thislackofinvestmenthasresultedinasituationwheremostpeopleindevelopingcountriesreceivenotreatmentwhatsoeverfortheirmentalhealthproblems.Lessthanonein10willgettreatmentfordepression,29whileinlowincomecountriesandformoreseveredisorderssuchasschizophrenia,thisfiguresfallstoonein50.30

Figure2:Percentageoftotalhealthspendingonmentalhealthcomparedtotheburdenofdisease(DALYsandYLDs)forallmentalhealthandneurologicalconditions

Reproduced from Patel V, Saxena S, De Silva M, & Samele C. Transforming Lives, Enhancing Communities: Innovations in Mental Health (2013) Report for the World Innovation Summit for Health10

Source: Global Disease Burden data 2010 (DALYs and YLDs)31 and WHO Atlas 2011 (mental health spending).3

Low-income countries

Lower middle- income countries

Upper middle-income countries

High-income countries

30

25

20

15

10

5

0

% of total health spending on mental health

Disability Adjusted Life Years (DALYs)

Years Lived with Disability (YLDs)


Huzeima’s story Reproduced with the kind permission of BasicNeeds

WhilepursuingherstudiesatateachingtrainingcollegeinGhana,25yearoldHuzeimabecameill.Asisfrequentlythecase,shewasadmittedtoatraditionalhealer’shomebyherfamilyandremainedthereforsixmonths.However,afewmonthsafterreturninghomeshebecameunwellagainandherparentstookhertohospitalwhereshewasreferredtotheNGOBasicNeeds.

AspartoftheBasicNeedscommunitybasedtreatment,Huzeimaattendedanoutreachclinicwhereshewasdiagnosedwithpsychosisandprescribedmedicationwhichhelpedimprovehercondition,bolsteredbythesupportHuzeimaandherfamilyreceivedfromaself-helpgroup.Huzeimasaid:“The group loaned me a small amount of money and with this I was able to buy food grains during the harvest season and sell it during the lean season. I was able to repay the loan and even made a small profit. I am back to life again”.

Theself-helpgroupalsoapproachedtheDistrictEducationDirectorrequestinghimtofindasuitableteachingpositionforHuzeima.AfterhearingthatHuzeimahaddroppedoutofteachertrainingduetoherillnessandwasdependentonherparents,theDirectorwasabletoofferheranon–professionalteachingpositionatalocalprimaryschool.

Today,HuzeimahasrecoveredandapartfromteachingsheisalsoSecretaryoftheNanumbaNorthDistrictAssociationofmentallyillpeopleandcarersinGhana,whosemainobjectiveistocoordinatetheactivitiesofself-helpgroupsintheNorthofGhanaandchampionissuesofmentalhealthandepilepsyinthedistrict.

Huzeima at a self-help group meeting in Ghana

Photo: BasicNeeds Ghana


Despite the scale of the global mental health challenge, there is much that can be done to address it. Good evidence exists for a range of cost-effective, feasible interventions to improve the health and well-being of people affected by mental health problems, even in low and middle income countries.32 Many of these solutions are capable of ‘turning the world upside down’ - ideas developed in resource poor settings from which the UK could learn. The problem is not what to do, but mobilising the political will, finance and human resources needed to do it.

Theinternationalcommunityhasalreadyagreedthewayforwardforglobalmentalhealth.InMay2013,all194memberstatesoftheWHOratifiedtheMentalHealthActionPlan2013-2020.33Thiscommittedtheworldtoachievingfourobjectives,eachwithcorrespondingglobaltargetstobereachedby2020:

1. Tostrengtheneffectiveleadershipandgovernanceformentalhealth2. Toprovidecomprehensive,integratedandresponsivementalhealth

andsocialcareservicesincommunity-basedsettings3. Toimplementstrategiesforpromotionandpreventioninmentalhealth4. Tostrengtheninformationsystems,evidenceandresearchformentalhealth

TheWHOActionPlan,alongwiththeConventionoftheRightsofPersonswithDisabilities,representsahistoricopportunityforGovernmentstoactonmentalhealth.Asasignatory,theUKneedstoconsiderwhatitsroleinmeetingtheActionPlan’sgoalsshouldbe,andhowitcanequipitsconsiderableglobalhealthanddevelopmentsectorstomeettheseends.OnecriticalapproachwheretheUKisalreadyhavinganimpactisworkingdirectlywithgovernmentstosupportthemtodevelopeffectivenationallevelmentalhealthpoliciesandplans.34,35PerhapsthesinglemostimportantthinginensuringthatnationalgovernmentsandinternationaldonorsprioritisementalhealthforinvestmentwouldbetoincorporateatargetformentalhealthintotheHealthGoaloftheforthcomingSustainableDevelopmentGoals(SDGs).Aninternationalcampaigntoachievethisisalreadyunderway.36

Threebroadsolutionshavebeensuccessfullyimplementedinlowandmiddleincomecountries:preventingmentalhealthproblemsfromdeveloping;treatingthemthroughcareandsupport;andpromotingtherightsandrepresentationofpeoplewithmentalhealthproblems.Examplesofthesearedescribedbelow,althoughmanyprogrammesuseacombinationofallthreesolutions.

2. What solutions exist?


Solution 1 Foster social and economic environments that promote mental wellbeing and prevent mental disorders from developing

Actioncanbetakentoimprovetheconditionsofdailylife,topromotementalwellbeingandpreventmentaldisordersdeveloping.Thisrequiresbroadinterventionsacrossmultiplesectors(e.g.environment,health,education,socialpolicy)andatmultiplelevels(family,community,national).37Examplesincludenationallevelpolicychangestorestricttheavailabilityofalcohol,suchasthosecurrentlybeingconsideredinMalawiandZambia,38andregulatorycontrolsontheimportandsaleoftoxicpesticidesinSriLankawhichresultedthenumberofsuicideshalvingovera10yearperiod.39

SomeofthisworkisalreadyhappeningthroughtheMillenniumDevelopmentGoals(MDGs).AlthoughmentalhealthisnotexplicitlymentionedintheMDGs,progresstowardsallofthesegoals(includingnon-healthgoalssuchasreducingextremepovertyandhunger,improvingeducation,andpromotinggenderequality)willhavepowerfuleffectsonpromotinggoodmentalhealthbyactingonthesocialdeterminantsofpoormentalhealth.37

Impactsofpovertyreductionprogrammesonmentalhealthcanbehardtopredictwithoutpurposefullymeasuringthem.Forexample,whilecashtransferstoparentsconditionalontheirchildattendingschoolhavebeenshowntoreducebehaviouralproblemsinchildren,somemicrocreditschemeshaveshownanegativeeffectonmentalhealth.40Trackingtheimpactofdevelopmentprogrammesonmentalhealthshouldberoutinepracticetoensuretheseimportanteffectsaretakenintoaccount,butthisisrarelydone.

ThereisanimportantopportunitytochangethisthroughthedraftingoftheSDGs,currentlyunderintensediscussionatagloballevelandexpectedtobefinalizedthroughtheUNin2015.Inadditiontoadvancingaglobalagendaofaccesstobasicmentalhealthserviceswithinhealthsystems,theSDGspresentarareandimportantopportunitytoalignactionaroundmetricsthatcapturewellbeingingeneral,aswellasspecificmentalhealthprioritiesforwhichcross-culturalmeasuresarewelldeveloped,suchasfordepression.

Promotionandpreventionstartswiththeearlyyears.Thereisrobustevidencefromhighincomecountriesthatgivingeverychildthebestpossiblestartwillgeneratethegreatestsocietalandmentalhealthbenefits.37Thereisgrowingevidencethatthesameistrueinlowandmiddleincomecounties,withsuccessfultrialsofinterventionsbycommunityhealthworkerspromotinggoodparenting,childnutritionandmaternalmentalhealthincountriessuchasJamaicaandPakistan.41Thereisalsogoodevidencethatschoolandcommunitybasedinterventionscanpromotementalwellbeingamongchildrenaged6-16yearsindevelopingcountries.42


Solution 2 Expand access to community based treatment and care for people who do develop mental health problems

Despitethecommonlyheldbeliefthatimprovementsinmentalhealthrequiresophisticatedandexpensivetechnologiesandhighlyspecialisedstaff,therealityisthatmostmentaldisorderscanbetreatedbynon-specialiststaffwithoutanymedicalequipment.ThetreatmentofmentalhealthproblemshasbeenshowntobeascosteffectiveasotherhealthtreatmentssuchasantiretroviraldrugsforHIV/AIDS,andthereturnsoninvestmentsinmentalhealthareconsiderable.43Thesetreatmentsarealsoaffordable:ascaleduppackageofcareforepilepsy,depression,psychosisandharmfulalcoholuseinsub-SaharanAfricaandSouthAsiaisestimatedtocostUS$3-4percapita.44

In2008theWHOlauncheditsflagshipmhGAPprogramme.TheaimofmhGAPistoexpandaccesstoservicesinlowresourcesettingsbyprovidingevidencebasedguidelinesforthetreatmentofarangeofmentalhealthproblemsbynon-specialistsinprimarycareinlowresourcesettings.7mhGAPnowformsthebasisofmanycountriesnationaleffortstoscaleupmentalhealthservices,supportedbytheWHOandamplifiedbyspecialistsworkingdirectlywithgovernmentsandotherstakeholdersonsituationappraisalandpolicysupport.34

Projectsinlowresourcesettingshaveusedthreebroadstrategiestosuccessfullyintegratementalhealthintocommunitycare.Allthesestrategiessharethecommonthreadoflocallyadaptingsolutionstobeculturallyappropriate.Thefirstovercomestheshortageofmentalhealthspecialistsbytask-sharingwithothercadres:thesecanbegenericprimaryhealthcareworkers,dedicatedmentalhealthcommunityworkers,speciallytrainedlaypeople,orotherhealthprofessionalsequippedwithmentalhealthcareskills.Forexample,theKenyanMedicalTrainingCollegehastrainedover2000frontlinenursesandclinicalofficerswitha5daymentalhealthcontinuingprofessionaldevelopmentcourse.ThisamountstonearlyhalfofKenya’sprimarycarepublicsectorworkforce.Ithasalsorunsimilartrainingforsomeprivatesectorworkers,faithbasedorganisationsandprisonnurses.45TheKintampoProjectisaUKNon-GovernmentalOrganisation(NGO)whichworksinpartnershipwiththeGhanaianMinistryofHealthtotraintwonewcadresofcommunitymentalhealthworkerswhoprovideservicesinallregionsinGhana.46Theprojecthasincreasedthetrainednationalmentalhealthworkforcebyover90percent,resultinginatriplingofthenumberofpeopleinGhanareceivingtreatment.47

Thereisanestablishedbodyofevidencefromtrialsinlowandmiddleincomecountriesthatdemonstratestheeffectivenessoflayhealthworkerdeliveredpsychologicaltherapies.48Thesestrategiesarenowbeingadoptedbygovernments,suchasinthenewDistrictMentalHealthProgrammeinIndiawhichrecommendsanewcadreofcommunity-based,non-specialistmentalhealthworker.49Task-sharingisonlysuccessfulifdeliveredthroughahealthsystemsapproachincludingon-goingtrainingandprofessionaldevelopment,supportivesupervision,clearreferralpathwaystospecialistcare,andaclearroleforthenon-specialistwithinthehealthsystem.

HealthsystemstrengtheningformentalhealthiscurrentlybeinginvestigatedintheEmergingmentalhealthsystemsinlow-andmiddle-incomecountries(EMERALD)project,fundedbytheEuropeanCommission.EMERALDaimstoidentifykeyhealthsystembarriersto,andsolutionsfor,thescaled-updeliveryofmentalhealthservicesinlow-andmiddle-incomecountries,andbydoingsoenhancehealthsystemperformanceandimprovementalhealthoutcomesinafairandefficientway.50


Thesecondstrategyinvolvesempoweringpeoplewithmentalhealthproblemstobeagentsofchange.Thereisnowglobalexperienceinthevalueofhavingpeoplewithmentalhealthproblemsinvolvedindevelopingservicesthatmeettheirneeds,andtobeinvolvedindeliveringthoseservices.HeartSoundsinUgandaengagespeersupportworkerswhoare‘expertsbyexperience’tosupportfellowserviceusersthroughengagingfamiliesandprovidingpsycho-education(seemaponpage20).51OtherexamplesincludeClubhouseInternationalwhichruns330communitycentresrunbyserviceusersin33countries,includinganumberoflowandmiddleincomecountries.52Theselean,service-userledmodelshavebeenshowntoworkequallywellinhighincomecountriessuchastheUSAandUK.

Healthservicemanagersmustalsobeempoweredtodefine,scale,andimprovecare,andtherehavebeenimportantadvancesinmakingavailableandapplyingQualityImprovement(QI)toolsforthispurpose.TheuseandspreadofgoodideasforhowtodelivercareoftenfailintheabsenceofgoodimplementationtoolsandQIhasbeenshowntobeeffectiveinfillingthatneedinthesesettingsforotherhealthconditions.53ThepotentialimpactofQImethodstohelpaccelerateadoptionofmhGAP-basedcareinverylowresourcedsettingsisbeingexploredthroughtheABillionMindsandLivesEarlyAdopterNetworkwhichlinksfundedprojectsscalingupprimarycareintegrationofmhGAP-basedcareacross5Sub-SaharancountrieswiththeInstituteforHealthcareImprovement,agloballeaderintheapplicationofQItohealthsystemsimprovement.54

Thethirdstrategyharnessesdevelopmentsin‘mHealth’:usingtechnologytoimproveaccesstocare.Telemedicineisaneffectivewaytoconnectpeoplewithscarcementalhealthspecialists,toincreaseaccesstoself-helptreatments,andtobuildthecapacityofthementalhealthworkforce.UseoftelemedicineisbeingsuccessfullyimplementedinTamilNaduinIndiawhereabuswithatele-psychiatryconsultationroomandamobilepharmacyvisitsruralareas.Atacostof£7perperson,theprojecthastreated1500peoplewithseverementaldisorders,70percentofwhomhavebeenreceivingtreatmentforoveroneyear.55Therearenumerouslow-cost,automatedpsychologicaltreatmentsforanxietyanddepressivedisordersdeliveredviatheinternetsuchasTHISWAYUP56whichhaveagrowingevidencebaseandhavegreatpotentialforincreasingaccesstopsychologicaltherapiesparticularlyinmiddleincomecountries.Technologyisalsobeingusedforcapacitybuilding,suchasintheeDataKprojectwhichusesfreelyavailablecomputer-basedcoursestotrainlargenumbersofprimaryhealthcareworkerstoidentifyandtreatalcoholusedisordersinKenya.57

“��Mental�health�needs�to�become�an�essential�part�of�our�approach�to�improving�primary�care,�strengthening�health�systems�and�achieving�universal�health�coverage”

Rachel Jenkins, Emeritus Professor of Epidemiology and International Mental Health, King’s College London


Solution 3 Advocate for the rights and representation of people with mental health problems, and for greater investment to improve access and services

Promotingmentallyhealthyenvironmentsandprovidingeffectiveandculturallyappropriatetreatmentandcarewillnothappenonthescaleneededtoaddressthecurrentcrisis,withoutincreasedinvestmentinmentalhealthindevelopingcountries.Forthistohappen,mentalhealthneedstobemorewidelyrecognisedasahumanrightandaneconomicandsocialpriority.58Thereisasmallbutgrowingnumberofservice-userledadvocacygroupsworkingincountriestoadvocateforimprovedservicesandcampaigningforchangestodiscriminatorylawsandpractices.ExamplesincludeKOSHISHinNepal59(seemaponpage20),andtheCentralGautengMentalHealthSocietyinSouthAfrica.60However,suchinitiativesarenotyetthenorminlowresourcesettings,andtheireffortsmustbeamplifiedthroughlinkageswithothersimilarinitiativesandbypolicysupportfromthehighestlevelwithinthecountrieswheretheyareworking.

Is global mental health culturally imperialist? Anon-goingdebateexistsoverwhetherimprovingaccesstomentalhealthinterventionsusedinhighincomecountriesmightdomoreharmthangood.Globalmentalhealthhasbeenlikenedto‘culturalimperialism’bysome-imposingWesterndiagnosesandtreatmentsontosocietieswithconflictingconceptionsofmentalhealth.Theseexternalinfluences,itissuggested,medicaliseandmedicatepeoplewithoutregardtoexistingsupportstructuresandlocalperspectives.61

Culturalappropriatenessisavitalpartoftheeffectivenessofmentalhealthinterventions,aspresentationofproblems,aswellaswhathelps,canvarybycontext.Thisisasharedproblemrelevanttomentalhealtheverywhere–betweendifferentlocalboroughsinonecity,asmuchasbetweendifferentcountries.

Thisdebatethereforeprovidesahelpfultensioninthefieldofglobalmentalhealth–challengingthoseworkinginlowandmiddleincomecountriestothinkdeeplyabouttheculturalappropriatenessofservices,theinvolvementofcommunities,wherelocalknowledgeandresourcesworkbest,andwhereoutsidesupportisneeded,andtocollaboratewithlocalexpertisetoresearchrelevantprotectiveandharmfulpsychosocialfactors.

Thechallengetowellmeaning,butill-consideredattemptstohelpiswelcome,butshouldnotleadtoinaction.Theexamplesquotedinthisreportshowhowknowledgeandskillsfromhighincomecontextsaredrawnuponandadaptedtomeetlocalneeds,consideringthecultureandresourcesofparticularlowincomecontextsthroughpartnershipswithlocalstakeholdersincludingserviceusers–andthatindoingsothereisequalopportunityformutuallearning.Someoftheseprogrammeshavethepotentialto‘turntheworldupsidedown’byprovidingimportantlessonsonhowtoaddressthelargeunmetneedformentalhealthcareintheUK.


James’ story Reproduced with the kind permission of the Peter C. Alderman Foundation (PCAF).

JamesresidesintheKitgumdistrictinnorthernUganda.Helosthisfatherbeforehewasborn,andhismothersufferedfromguineaworm

infection.HewasabductedbytheLord’sResistanceArmyatage14,wherehewastrainedasasoldierandsenttoSudan.Hewasbeaten,starvedandforcedtokill,andescapedmanyhelicoptergunshipattacksandbombs.

AfterhisescapefromtheLRA,JameswasregisteredataPCAFclinicwherethesocialworkernoticedthathewouldnottalkorsmile.Hesufferedfromnightmares,lossofappetiteandhopelessnessaboutthefuture.Thesocialworkernoticedthathelikedtodrawandgavehimcrayonsandapapertotellhisstory.HeproduceddozensofextraordinarydrawingsofhisexperienceinthebushasasoldierwiththeLRA.

Inmonthsofintensivetreatment,Jamesopenedupandbegantoregainhislife.HehasbeenmakingartworkforPCAFeversince.Henowworksforagraphicdesignstudio,hasasafeplacetolivewithhiswifeandchild,andthroughananonymousdonor,hasafullrangeofartsupplies.

YoucanseeavideoofJamestalkingabouthisexperience,andseeagalleryofhiswork,onthePCAFwebsite

Photo: Cynthia MacDonald

http://www.petercaldermanfoundation.org


Improving mental health globally

All of the projects and organisations highlighted in this report and on this map are profiled on the Mental Health Innovation Network in a growing database which currently hosts more than 85 innovative examples of best practice in mental health promotion, prevention and treatment from around the world.

TheCanadian Governmentis

fundingtheworld’slargestbodyofglobalmentalhealthresearchprojectsthroughGrand Challenges Canada.Theyhaveinvestedover£17millionin49projectsacrossthedevelopingworldsince2011,withprojectsincludingestablishingfamilynetworksforchilddevelopmentaldisordersinPakistan 62,expandingandstrengtheningmentalhealthservicesinprimarycareinHaitifollowingtheearthquake,63andusingindigenousnetworksforcasedetection,referralandfollow-upinUganda.64

TheIndonesian Ministry of Health

hasimplementedaprogrammeforthenation-wideeliminationoftheuseofphysicalrestraintstoprotectthehumanrightsofpeoplewithseverementalillness.Theyestimatethat18,800peopleinthecountryarecurrentlyrestrainedinthisway.Amulti-prongedapproachincludingensuringallocationofsufficientmentalhealthbudgets,providingcommunity-basedmentalhealthservicesandintensiveeducationcampaignshasresultedin3500peoplebeingreleasedfromchainssince2012.65

TheUKNGOBasicNeeds worksin

11countriesinAfricaandAsiatoempowerpeoplewithmentalhealthproblemslivinginpovertythroughcommunity-orientedtreatmentandself-helpsupport,addressingtheirmedical,socialandeconomicneeds.AsofJune2014,BasicNeedshasreachedover120,000peoplewithmentalillnessandover496,000carersandfamilymembers,atacostofapproximately£20peraffectedindividual.66

ThePRogramme for Improving Mental

health carE (PRIME)isapartnershipofresearchersandMinistriesofHealthfundedbyDFIDtodevelop,evaluateandscaleupdistrictlevelmentalhealthcareplansintegratingmentalhealthintoprimarycareinNepal,India,Ethiopia,UgandaandSouth Africa.Finalresultsareduein2017,butsofartheprojecthasinformednationallevelpolicychangesinfourofthefivecountries.67

http://mhinnovation.net/innovations

http://www.grandchallenges.ca/grand-challenges/global-mental-health/

http://mhinnovation.net/innovations/chain-free-pasung-program

http://mhinnovation.net/innovations/chain-free-pasung-program

http://mhinnovation.net/innovations/basic-needs

http://mhinnovation.net/innovations/prime-programme-improving-mental-health-care




TheEthiopian Ministry of Health

hasmadesignificantprogresstowardsdevelopinganationalmentalhealthworkforcethroughtrainingprogrammesforallcadresofhealthworkersfrompsychiatrists,psychiatricnursesandcommunityhealthworkerstoPhDlevelmentalhealthresearchers.Todate115psychiatricpractitioners(MSclevel)and491psychiatricnurseshavebeentrained,andthenumberofpsychiatristshasincreasedfrom12to40withallbutthreeremaininginthecountry.68

ThePeter C. Alderman

Foundation (PCAF)workswithgovernmentsinUganda,KenyaandCambodiatoestablishtraumaclinicsdeliveredthroughpublic-privatepartnershipsinpost-conflictsettingsusingtrainedlayhealthworkersandoutreachservices.PCAF alsoopened thefirstmentalhealthWellnessClinicinLiberia.Morethan100,000survivorsofterrorismandmassviolencehavesofarbeentreatedbyPCAFatacostof£26perpatientperyear,withevaluationsshowingsignificantreductionsinsymptomsanddisabilityinindividualswhoreceivetreatment.69

InNepal,mentalillnessislegalgroundsfordivorce.

Asaresult,womenlivingwithmentalillnessarecommonlyabandonedonthestreetsbytheirhusbands.The National Mental Health Service User Organization KOSHISH,whichisrunbyserviceusers,providesemergencysupportforabandonedwomen,whilefightingdiscriminatorylawstoensurethattheirrightsareprotected.AfternearlyadecadeofadvocacybyKOSHISHandpartners,in2014thegovernmentcommittedtoestablishamentalhealthunittoaddressthementalhealthcareneedsofallpeoplelivingwithmentalillnessinNepal.59

TheButabika East London Linkisa

partnershipbetweenEastLondonNHSFoundationTrustandButabikaPsychiatricHospitalinUganda,fundedbytheTropicalHealthEducationTrustandDFID.70TheyhavedevelopedanumberofprogrammestoimprovementalhealthcareinUganda,includinghelpingtodevelopchildandadolescentmentalhealthservicesatthehospital,trainingPsychiatricClinicalOfficerswhoprovidemuchofthementalhealthservicesinruralUganda,andapartnershipwithHeartSoundsUgandatrainingpeer-supportworkerstoprovidecommunityoutreachservicestopeopledischargedfromthehospital.51

Improving mental health globally

http://mhinnovation.net/innovations/national-capacity-building-program-ethiopia


http://mhinnovation.net/innovations/peter-c-alderman-trauma-clinics



http://mhinnovation.net/organisations/koshish-national-mental-health-self-help-organization



http://mhinnovation.net/organisations/butabika-east-london-link

http://mhinnovation.net/organisations/butabika-east-london-link


UK government is doing more than most to address the challenge of global mental health and British institutions are slowly beginning to recognise the importance of this field. Still, mental health remains an afterthought in most of the UK’s global health and development work. Many excellent programmes exist, but they are isolated. The impact of the UK’s wider international development efforts to create stable, sustainable communities on mental health goes unmeasured.

Department for International Development

DFIDstandsoutasoneoftheonlynationalaidagenciestohaveaportfolioofworkfocussedonmentalhealth.71However,theseprojectsarelimitedinnumberandscope,comprisinglessthanonepercentofitsoverallhealthbudget.

DFID’smostnotableprogrammeisthe£6millionPRIMEresearchstudytodevelopandevaluatedistrictlevelmentalhealthcareplansinfivecountriesinAfricaandAsia(seemaponpage20).Inaddition,DFIDisfundinganumberofprojectsinindividualcountries,suchasinGhanawhere£7millionhasbeenallocatedoverfiveyearstosupportamixofdirectserviceimprovements(aBasicNeedsprogrammetoestablishcommunitymentalhealthcareandafaith-basedreferralsystemsprojectwiththeChristianHealthAssociationofGhana)andpolicydevelopment(assistingGhana’snewlyestablishedMentalHealthAuthority).DFIDisalsoleadingworkonmentalhealthincrisissituations,forexampledevelopingtechnicalguidanceforadviserstoprovidepsychosocialsupportfollowinghumanitariandisasters.

NGOs and others working in international development

MentalhealthisconspicuouslyabsentfromtheUK’svibrantglobalhealthNGOsector,potentiallylimitingtheimpactoftheirdevelopmentprogrammesthroughignoringthecriticalmissingpieceofsustainabledevelopment:mentalhealth.Fewofthemajorhealthcharitiescontactedcouldnameanyprojectswhichaimedtoimprovementalhealthinlowandmiddleincomecountries,orwherementalhealthimpactsofdevelopmentprogrammeswerebeingmeasured.Thislackwaslargelyseenasfunding-driven–mentalhealthwasnotsomethingthatdonorswouldreadilysupportoverotherdiseaseareas.ItisalsopossiblethatpublicstigmaintheUKmeansfundraisingformentalhealthismorechallenging.

ExceptionsexistintheformofasmallnumberofUKNGOswhodoincludementalhealthaspartoftheirwiderwork,includingVSO,InternationalMedicalCorpsandtheTropicalHealthEducationPartnership.ThereisanevensmallernumberofrelativelysmallbuthighlyregardedUKNGOswhoworkexclusivelyonmentalhealth,includingBasicNeedsandMindsforHealth.MindsforHealthformspartnershipswithexistingorganisationsindevelopingcountriestoimproveaccesstomentalhealthcareandtacklethesocialcausesandconsequencesofmentalhealth.BasicNeeds’lean,communitybasedapproachtoimprovingthelivesandlivelihoodsofpeoplewithmentalhealthproblemsacross11countriesisfeaturedonthemap(page20).

3. The UK’s current contribution to global mental health


Academic institutions

UKuniversitiesandresearchfundingbodiesaremakingsomesignificantcontributionstoourunderstandingofglobalmentalhealth.Inparticular,theUKhostsoneoftheworld’sleadingresearchhubsinthefield:theCentreforGlobalMentalHealth,acollaborationbetweentheLondonSchoolofHygiene&TropicalMedicineandKing’sHealthPartnersAcademicHealthScienceCentre.

Intermsofresearchfunding,mostofthemajorUKresearchfunderscannameasmallnumberofglobalmentalhealthprojectstheysupport.TheMedicalResearchCouncil,theWellcomeTrustandtheEconomicandSocialResearchCouncilfundavarietyofresearchprojectsinlowandmiddleincomecountries,includingthesocialdeterminantsofmaternalmentalhealth,trialsformentalhealthinterventions,andstudiestounderstandthementalhealthofHIVpositivechildren.ThereisapromisingdevelopmentintheformationanewUKcharity,MQ:TransformingMentalHealth,thoughtodatetheyhavenotfundedanyresearchinlowandmiddleincomecountries.

NeuroscienceisamajorareaofinvestmentforseverallargeUKresearchfundinginstitutions.Althoughthisworkcouldultimatelyleadtobreakthroughsinmentalhealthtreatments,littleofthisresearchisalignedwiththeprioritiesoflowandmiddleincomecountries,andthetreatmentsthatresultarelikelytobeoutofreachformanyhealthsystems.

NHS

TheNHShasalsobeencontributingtoimprovingglobalmentalhealththroughanumberofpartnershipswithgovernmentsandprovidersinlowandmiddleincomecountries.NHSmentalhealthtrustsoperatelinksthroughtheDFID-fundedHealthPartnershipsScheme.Thesepartnershipslargelyfocusontrainingspecialist,non-specialistandlaymentalhealthworkersinordertoexpandaccesstocareinthepartnercountry.Onesuchlink,betweentheEastLondonNHSFoundationTrustandtheButabikaPsychiatricHospitalinUganda(seemaponpage20)hasdemonstratedthemutualvalueofthesepartnerships:Butabikanowhasmanymoretrainedmentalhealthworkerstodelivercare,whiletheNHSstaffinvolvedhavehelpedtoexperienceandadaptnewapproaches–suchasnarrativetherapy–thatarenowsuccessfullybeingusedwithlocalcommunitiesinEastLondon.

UK’s biggest contributions go unnoticed

TheprogrammesnotedabovegiveasnapshotofthecurrentUKactivitiesthatexplicitlyaimtoimprovementalhealthindevelopingcountries.Thegreatestcontributionstothisfieldwillnothoweverbethesededicatedprojects,butthemuchlargerglobalhealthanddevelopmentworkofBritishgovernment,charities,companiesandinstitutions.Assection1outlined,economicempowerment,goodphysicalhealth,security,equalityandhumanrightscanallhaveahugelybeneficialimpactonmentalhealth.ThereareamultitudeofsuchprogrammesacrossallsectorsoftheUK,butthementalhealthimpactsoftheseprojectscurrentlygounmeasured–despitesimple,cheapandwellvalidatedtoolstocapturethis.Thismeanswedonotknowwhatworks,orhowtofactormentalhealthbenefitsintoresourceallocationdecisions.Incorporatingthesetoolsintoon-goingandfutureprojectsrunbyDFID,NGOsandUKresearchwouldbeasimplechangethatwillprovideawealthofinformationaboutthetypesofprojectsthatarehavingpositivementalhealthoutcomes.

“��Frankly,�mental�health�is�not�an�attractive�subject�to�many�funders:�it’s�complex�and�there’s�a�lack�of�knowledge�about�the�extent�and�urgency�of�the�problem”

Chris Underhill, Founder Director, BasicNeeds


Mental health problems must be tackled to achieve sustainable development. This report recommends four key steps to achieve this. Our major health and development institutions must do more and act differently: thinking about mental health in all that they do, measuring mental health impacts of existing programmes and showing global leadership.

Recommendation 1

TheDepartmentforInternationalDevelopment(DFID)to‘integrate’‘evaluate’and‘replicate’globalmentalhealthinitsprogrammesinordertosupportcountriestoimplementtheWHOActionPlan

IntegrateDFIDshouldconducta‘mentalhealthinallpolicies’reviewtoassesswhereandhowmentalhealthcouldbeintegratedintoitsexistingwork.Inparticular,itshouldseektocometoaclearanddetailedviewofitsroleinhelpingcountriesachievetheWHOMentalHealthActionPlanobjectives.Itshouldalsoconsidercost-effectiveinvestmentsthataimatbroadersystemsstrengtheningalongthekeyareasemphasizedheresuchason-goinginfrastructuresfortrainingandmaintainingatask-sharingandcommunity-basedworkforce,capabilitiesforsmartuseofmobilehealthtechnologies,qualityimprovementmethods,empowermentandcommunitymobilization

EvaluateAsafirststep,DFIDshouldincorporatementalhealthimpactmetricsintoitsexistingprogrammesthatarelikelytobehavingasignificantimpactonmentalhealth(suchaspovertyreductionandgenderequalityprojects).ValidatedmeasuresarenowwidelyavailableandwouldbeaminimaladditionalburdenforrelevantDFIDfundedprojectstoadopt.ThiswillallowDFIDtobuildupamuchbetterpictureofwhereitisalreadymakingadifference

ReplicateAsDFID’sexistingmentalhealthinitiativesmatureandshowsuccessfuloutcomes,itshouldcommittoscalingupandadaptingtheseevidence-basedapproachestomuchlargergeographicareas.Thisshouldbedeliveredwithanappropriateincreaseinfundingforbothcivilsocietyandgovernments

TheUKhasrecognisedtheneedforacomprehensiveglobalstepchangeinthesupportformentalhealthavailableinlowandmiddleincomecountries.Thisincludesscale-upofcommunitybasedservices,strengthenedleadershipandgovernance,moreresearch,andsystemsforpromotionandpreventioninmentalhealth.

AlthoughDFIDisalreadydoingmorethanmostdevelopmentagenciesonthesepriorities,theinitiativesoutlinedintheprevioussectionappeartobeisolatedwithintheDepartment’sportfolio.ThisreviewfoundtheretobenocoherentorstrategicunderstandingofhowmentalhealthshouldfactorintoDFID’swiderhealthanddevelopmentwork.

4. Doing more and acting differently


Thisreportisnotthefirsttomakethisobservation.TherecentInternationalDevelopmentCommitteeinquiryintodisabilityanddevelopmentnotedthedisproportionatelylowlevelofDFIDspendingonmentalhealth,andthelimitedgeographicalcoverageofthiswork.71

ItrecommendedthatDFID“thoroughlyappraisethecase”forspendingmoreonmentalhealthandexplainitsreasonsifitdecidesagainstincreasingfunding.TheDepartment’sresponsetothiswasinsufficient,statingthatits“focusisonensuringthatthisisincludedinourworkonhealthsystemsstrengthening”withoutgivingdetailastohow.71ThethreespecificactionsrecommendedbythisreportwouldimproveDFID’sunderstandingandstrategicresponsetotheglobalmentalhealthchallenge.

Recommendation 2

NGOsandothersworkingininternationaldevelopmentshouldsupportstafftounderstandtheneedsandcapacitiesofpeoplewithmentalhealthproblems,encouragetheinclusionofpeoplewithmentaldisordersintheirgeneraldevelopmentprogrammes,setupnewmentalhealthspecificprogrammes,andmeasuretheimpactoftheirprogrammesonmentalhealth

Sustainabledevelopmentwillnotbeachievedifthehugechallengeofmentalhealthisnotaddressed.ThisrequiresexistingNGOsandothersworkingininternationaldevelopmentwhodonotcurrentlyaddressmentalhealthtoincorporatementalhealthpreventionandpromotionprogrammesintotheirwork,andmeasurethementalhealthimpactsofexistingprogrammestounderstandtheireffectondevelopment.AsignificantbarriertoachievingthisisthelackofspecialistexpertiseinmentalhealthwithintheNGOsectorwhichmeansthatpeoplewithmentalhealthproblemsareeitherexcludedfromprogrammesorincludedunderthedisabilitybannerinonlyacursoryway.InternationalinitiativessuchastheMentalHealthandPsychosocialSupportnetworkandtheMentalHealthInnovationNetworkwhichprovideexpertsupport,informationsharingandcapacitybuildingmaterials,alongwithexistingmentalhealthNGOssuchasBasicNeeds,canbetappedtoincreasetheexpertiseofNGOstaff.

Recommendation 3

Professionalbodiesandmentalhealthproviders,withthesupportofgovernment,shouldestablishandexpandtrainingandresearchpartnershipswithlowandmiddleincomecountries–seekingtoteachandtolearnprofessionalandimplementationskills,tacklingdiscriminationandpolicyreform

TheUKcanmakealargecontributiontomentalhealthinlowandmiddleincomecountriesbysharingitsknowledgeandskills.Conversationswithmentalhealthleadersinresource-constrainedsettingsrevealedacriticalshortageoftrainingresourcestodevelopskilledspecialist,non-specialistandlaymentalhealthworkers.Britishassistancewouldbehighlyvaluedin:

Trainingofexistingprimarycareworkersinmentalhealth Continuingprofessionaldevelopmentofmentalhealthstaff Communicationsexpertisetoincreasepublicawareness,promote

self-helpstrategies,andtacklediscrimination Legalandpolicyreforms IntegrationofmentaldisordersintoHealthManagementInformationSystems

“��It�is�important�not�to�have�a�situation�where�different�health�issues�are�simply�competing�for�the�same�finite�resources.�Building�strong�health�systems�that�see�the�person�as�a�whole,�recognising�mental�and�physical�health�is�really�important.”

Jane Edmondson, Health of Human Development, Department for International Development

http://www.mhpss.net

http://www.mhpss.net

http://www.mhinnovation.net


NotonlydoestheUKhavestrengthintheseareas,butcruciallyitalsohasthelinkstomakethesepartnershipshappen.MentalhealthstaffintheUKareevenmoreinternationalinbackgroundthanthegeneralNHSworkforce.Psychiatry,forexample,isthethirdmostinternationalmedicalspecialtyintheNHS.72Forthreecountries(allrecipientsofDFIDfunds)theUKemploysmorepsychiatristsfromthatcountrythanremainthere–Nigeria(214-114),Zambia(9-2)andMalawi(1-0).73TheseDiasporalinksofferanimportantuntappedresourcetheUKcouldusetogivebacksomeofwhatwehavegained.

Astheprevioussectionhighlighted,theUKalsobenefitsfrommentalhealthpartnerships.TherecentTurningtheWorldUpsideDown(www.ttwud.org)awardsshowstheNHShasmuchtolearnfromlowandmiddleincomecountriesaboutimprovingthehealthandlivesofpeoplewithmentaldisorders.The34projectsshowhowinnovativeapproachesbeingtakeninlowresourcesettingsofferideasandinitiativesthatBritaincouldadoptandadapt.ParticularattentionshouldbegiventopartnershipswithpartsoftheworldwheretheUKhassignificantDiasporacommunities,sinceoutcomesforblackandethnicminoritieswithmentalhealthproblemsinBritainaresignificantlyworsethanforwhiteBritishserviceusers.Developingandlearningfrominnovativesolutionsincommunities’culturesoforiginmaybeonewayofachievingthis.

Recommendation 4

TheUKshouldlobbyfortheinclusionofthefollowingmentalhealthtargetwithintheHealth Goalin the SustainableDevelopmentGoals.

“Theprovisionofmentalandphysicalhealthandsocialcareservicesforpeoplewithmentaldisorders,inparitywithresourcesforservicesaddressingphysicalhealthandworkingtowardsuniversalcoverage.”

Theworldlacksaneffectivearchitecturetosupportglobalactiononmentalhealth,partlyduetotheexclusionofmentalhealthfromtheMDGs.TheWHOhasgiveninvaluablesupporttomanylowandmiddleincomecountriesinrecentyears,includingtheMentalHealthActionPlan.However,thiscommitmentisnotattachedtoanysignificantlevelsoffundingforexpandedservices.

Anumberofsignificantopportunitiestoaddressthisgapexistinthenearfuture.TheseincludetheWorldBankandWHOhighlevelmeetingondepressioninAutumn2015,andfurthermilestonesinthedevelopmentandimplementationoftheSustainableDevelopmentGoals.TheUKwillhaveakeyroleinbothofthesesummits,andshouldcallinternalmeetingswithingovernmentwellinadvancetocometoaclearUKpositiononwhatshouldbedonetostrengthentheglobalarchitecturesupportingmentalhealth.TheUKshouldnotmissthisopportunitytoleadthesechanges,andinparticulartoensurethananynewinitiativesareprincipallygovernedbyandforlowandmiddleincomecountries.

PerhapsthesinglemostimportantthinginensuringthatnationalgovernmentsandinternationaldonorsprioritisementalhealthforinvestmentwouldbetoincorporateanadditionaltargetformentalhealthintotheHealthGoaloftheforthcomingSustainableDevelopmentGoals(SDGs).Thistargetmustexplicitlyseekparityofesteembetweenphysicalandmentalhealth,workingtowardstheultimategoalofuniversalcoverage.Toachievethis,countrieswillneedtosetthemselvesatransitionplantoincreasecoverageoverarealistictimeframe,includingthecollectionofrelevantlocaloutcomeindicatorssuchasmentalhealthdiagnosesrecordedinprimaryhealthcare,whichcanbeusedtotrackprogressovertime.


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Those who gave oral evidence to the review:

GaryBelkin NewYorkCityDepartmentofHealthandMentalHygieneJaneEdmondson DepartmentforInternationalDevelopmentKenGrant HLSPRachelJenkins King’sCollegeLondonVikramPatel LondonSchoolofHygiene&TropicalMedicineGrahamThornicroft King’sCollegeLondonChrisUnderhill BasicNeeds

Those who submitted written evidence or were interviewed individually:

NatashaAbrahams BasicNeedsDaveBaillie EastLondonNHSFoundationTrustDineshBhugra WorldPsychiatricAssociationPatBracken WestCorkMentalHealthServiceCatherineCampbell LondonSchoolofEconomicsMaryChambers KingstonUniversitySarahCotton InternationalCommitteeoftheRedCrossBhargaviDavar CentreforAdvocacyandMentalHealth,IndiaSubodhDave BritishAssociationofPhysiciansofIndianOriginMatrikaDevkota KOSHISH,NepalHervitaDiatri UniversityofIndonesiaVictorDoku MentalHealthEducatorsintheDiasporaRowanEl-Bialy MemorialUniversityofNewfoundlandConorFarrington UniversityofCambridgeSumanFernando LondonMetropolitanUniversityMichelleFunk WorldHealthOrganizationJaneGilbert DepartmentforInternationalDevelopmentRexHaigh BerkshireHealthcareNHSFoundationTrustCharlotteHanlon AddisAbabaUniversity,EthiopiaGregHarrison SheffieldTeachingHospitalsNHSFoundationTrustPeterHughes RoyalCollegeofPsychiatristsJillIllife CommonwealthNursesFederationDavidIngleby UniversityofAmsterdamSumeetJain UniversityofEdinburghJanakaJayawickrama UniversityofYorkIanB.Kerr CoathillHospital,ScotlandJayasreeKalathil SurvivorResearchValentinaLemmi LondonSchoolofEconomicsBlakeleyLowry PeterC.AldermanFoundationJohnMayeya MinistryofHealth,ZambiaPollyMeeks NationalAuditOfficeHughMiddleton UniversityofNottinghamAkimMogaji NewMediaNetworksMatthewMuijen WorldHealthOrganizationEuropeMahmoudMussa MinistryofHealth,ZanzibarSamuelOkpaku CentreforHealth,CultureandSociety,USAMilenaOsorio InternationalCommitteeoftheRedCrossNimishaPatel UniversityofEastLondonSoumitraPathare CentreforMentalHealthLawandPolicy,IndiaAlisonPavia PeterC.AldermanFoundationAlbertPersaud CareIfMargreetPeutz CentralandNorthWestLondonNHSFoundationTrustSabahSadik MinistryofHealth,IraqAbegailSchwarz ProgrammeforImprovingMentalHealth(PRIME)MortenSkovdal UniversityofCopenhagenR.Srivatsan AnveshiResearchCentreforWomen’sStudies,IndiaDerekSummerfield King’sCollegeLondonPhilThomas UniversityofBradford


SamiTimimi UniversityofLincolnRossWhite UniversityofGlasgowMaureenWilkinson CheshireandWirralPartnershipNHSFoundationTrustTedlaWolde-Giorgis MinistryofHealth,EthiopiaAdrianWorrall RoyalCollegeofPsychiatrists

Parliamentarians who took part in this review:

PeterBottomleyMPLordCrisp(Reviewco-chair)ViscountEcclesMegHillierMPBaronessMashamJamesMorrisMP(Reviewco-chair)LordPatelLordRibeiro

This review was funded by the All-Party Parliamentary Group on Global Health, who would like to thank their supporting organisations:

Bill&MelindaGatesFoundationCambridgeUniversityHealthPartnersImperialCollegeLondonInstituteforGlobalHealthInnovationKing’sHealthPartnersTheLancetLondonSchoolofHygiene&TropicalMedicineManchesterAcademicHealthScienceCentreUniversityCollegeLondonGrandChallengeofGlobalHealthUniversityofOxford

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All-PartyParliamentaryGroup(APPG)onGlobalHealthOfficeofLordCrisp,FieldenHouse,13LittleCollegeSt,London,SW1P3SH

+44(0)[email protected]

www.appg-globalhealth.org.uk

All-PartyParliamentaryGroup(APPG)onMentalHealthMrJamesMorrisMP,HouseofCommons,LondonSW1A0AA.

+44(0)[email protected]

November2014

http://www.appg-globalhealth.org.uk/

mental health for sustainable development€¦ · yet mental health is generally given a very low...

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