Access to Mental Healthcare
"Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane" [Martin Luther King, Jr, Chicago, 25 March 1966]
In 2005 the World Health Organisation (WHO) declared support for health systems which provide universal coverage of health services- 'securing access by all citizens to appropriate promotive, preventive, curative and rehabilitation services at an affordable cost'. Unfortunately, for much of the world's population, particularly in deprived communities in Low and Middle Income countries, access to essential care is not a reality. Global and local inequities in access to mental healthcare are particularly pronouced. We are calling for a scaling up of equitable and cost-effective mental healthcare in developing countries.
What we know:
Scarcity
- Mental health problems account for 13% of the global burden of disease (DALYs)* and 32% of all years lived with disability worldwide,[1] yet receive only 2-4% of world health expenditure[2] and 0.8% of WHO funding.[3]
- Resources for mental health are particularly scarce in lower income countries when compared with burdens. Less than 1% of health budgets is available for mental health in 79% of countries in Africa and 63% of countries in South & South East Asia.[4]
- This is reflected in large global inequities in mental health services on the ground. In low income countries there are 2.4 beds per 100,000 population compared to 75 beds per 100,000 in high income countries. [4]
- The resultant 'treatment gap', between those who need treatment and those who receive it, is widest in Low and middle income countries where 50-90% of patients with serious mental illnesses do not have access to essential care.[2]
- Global inequities in availability of human resources for mental health , psychiatric medications and community resources for mental health contribute to 'treatment gaps' in developing countries and are explored elsewhere in this GMH advocacy series.
* Disability Adjusted Life Years - a summary of years of life lost (premature deaths) and years lived with disability (illness)
Inequity
- Poverty is associated with mental illness in vicious cycles. Poor education, low income, unemployment, social exclusion and poor physical health have been found to be risk factors for mental illness throughout the life-cycle, irrespective of society or country.[5] Often vulnerabilities compound: for instance women in South Asia are at greatest risk of attempted suicide and common mental disorders where gender inequalities and economic hardship interact.[6] Equally, mental illness can lead to loss of income, unemployment and social exclusions for both patients and families.
- This means that rates of mental disorders are often highest in young people, women and in poor and rural communities.[7] Unfortunately, the availability of essential mental healthcare is particularly limited in these populations.[4]
- Even where scarce mental health services exist, stigma, social marginalisation, geographic distance and costs (lost work days, transport and healthcare fees) present substantial barriers to accessing care for disadvantaged and vulnerable groups. Delays in accessing treatment can lead to poorer mental health and reduce benefits from therapy. [7]
- Out-of-pocket expenditures (i.e. paid at the time) associated with accessing healthcare have been found to be a leading cause of impoverishment in low and middle income countries. 'Catastrophic' health expenditures, which displace spending on essentials such as food and housing and create debt, have been found to be more likely in areas with higher levels of poverty and health systems that rely on out-of-pocket expenses rather than (social) insurance or tax-based funding. [8] Over one third of low income countries rely on out-of-pocket financing of mental healthcare compared to 3% of high-income countries[2].
- Mental illness may place patients and families at particular risk of impoverishing health expenditures, because of the need for ongoing care.
Inefficiency
- Mental healthcare in developing countries is often delivered through large, centralised institutions. This model of delivering services is costly and inaccessible to populations most in need of care.
- Only 50% of countries provide community-based services or training for mental healthcare in primary care.
- A lack of human resources and research also undermines attempts to create effective and efficient services.
What we are calling for:
As part of the Movement for Global Mental Health, we are calling for health sectors, governments and the international community:
To reduce the SCARCITY of mental healthcare in low and middle income countries by increasing available resources
In particulary we support::
- Increased international and national budgets for mental healthcare, appropriate to the health burdens of mental illness in developing countries.
- Providing the essential resources and training for general health workers to manage mental illness.
To address INEQUITIES in mental healthcare by reducing barriers to access and costs for patients and families from deprived populations
In particular we support:
- Developing mental health services appropriate for currently under-served populations in rural and deprived communities.
- Measures to protect patients and families from impoverishment due to spending on healthcare. This includes the inclusion of mental illness in social insurance or tax-based pre-payment systems where available.
To improve the EFFICIENCY of mental healthcare in low and middle income countries by investing in services that meet the needs of local populations.
In particular we support:
- Investment in community based services
- The integration of mental health services with general healthcare at local levels (e.g. in primary care).
- Novel methods of delivering mental healthcare, such as the use of community (lay) healthworkers, which can overcome scarcity of human and other resources.
What you can do:
1) Push for a UN General Assembly Special Session on Mental Health
In September 2011 the UN General Assembly (UNGA) will hold a special summit on Non-communicable diseases (non-infectious diseases). It is hoped this will successfully galvanise a global response to conditions such as heart disease, stroke, cancer, chronic lung diseases and diabetes in the same way as it did for HIV/AIDS in 2001.
Yet, as a letter in The Lancet medical journal (14th Aug 2010) highlighted, mental health was conspiciously absent from this special summit's agenda. The author's called for a UNGA Special Session on Mental Health and an accompanying UN Resolution on Mental Health.
- The Movement for Global Mental Health is coordinating efforts to make this vision a reality (see here)
- At a national level we are asking members to write to the UK permanent representative to the UN, Sir Mark Lyall Grant to push for a UN Special Summit on Mental Health (here).
- Sign an online petition to push for mental health in the UNGA special session (here).
2) Join the Movement for Global Mental Health's 'Call for Action'
The Movement's "Call for Action" outlines an agenda for meeting challenges in Global Mental Health. By joining the Movement for Global Mental Health you are supporting this call and increasing the strength of this global campaign.
The 'Call for Action' covers all the points raised in this advocacy series and if you do not have time for other advocacy work please consider taking 2 minutes to join the movement (here).
3) Write to your local MP.
Minds for Health has created a letter which you can personalise and send to your local MP (here). This letter:
- Outlines the facts and calls for action detailed on this page.
- Asks for the MP to highlight the need for scaling up mental healthcare in developing countries and to press the UK government (e.g. through the Department for International Development - DfID) to dedicate more resources to global mental health.
- Asks for the MP to secure the commitment of the UK's permanent representative to the UN in pushing for a resolution and UNGA Special Session on Mental Health.
Further resources
References
[1] Mathers C and Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine, 2006; 3:e442.(link)
[2] Saxena, S, Thornicroft, G, Knapp, M, Whiteford, H: Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 2007; 370: 878–89 (link).
[3] Raja, S, Wood, SK, de Menil, V, and Mannarath, SC, Mapping mental health finances in Ghana, Uganda, Sri Lanka, India and Lao PDR. International Journal of Mental Health Systems, 2010, 4:11.(link)
[4] World Health Organisation: Mental Health Atlas 2005. The World Health Organisation (WHO), Geneva, Switzerland, 2005. (link).
[5] Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bull World Health Organ 2003; 81: 609–1.
[6] J Maselko, V Patel: Why women attempt suicide: the role of mental illness and social disadvantage in a community cohort study in India. J Epidemiol Community Health 2008; 62:817-822. (link)
[7] Eaton, J and Patel, V: A Movement for Global Mental Health. Afr J Psychiatry 2009;12:1-3. (link)
[8] Xu, K, Evans, DB, Kawabata, K, Zeramdini, R, Klavus, J, Murray, CJL: Household catastrophic health expenditure: a multicountry analysis. Lancet 2003; 362: 111–17. (link)