A United Front for Global Mental Health

This entry is about the second All Party Parliamentary Group (APPG) session on global mental health. A recap of the of first APPG session, written by Victoria de Menil and Valentina Iemmi, can be found here: "Have Your Say on the Treatment Gap in Global Mental Health".

Building Momentum

On Monday 7th July, the UK All Party Parliamentary Groups (APPGs) on global health and mental health held their second oral evidence session to address the question: “How should the UK respond to the global mental health challenge?”

Chaired by Lord Nigel Crisp, former Chief Executive of the National Health Services, this session extended a conversation that had begun in December 2013 with the publication of the World Innovation Summit for Health (WISH) report on mental health. At a session of the House of Lords the same month, Lord Crisp asked the UK government to respond to the report’s recommendations.

Six months later, the first oral evidence session highlighted the need for action, pointing to increasing international attention and a growing evidence base for cost-effective interventions to improve the lives of people living with mental health problems in low- and middle-income countries (LMIC) around the world.

The aim of the second session was to help define what the recommended actions should be. Four expert witnesses representing diverse perspectives were invited to discuss the UK’s progress to date and the way forward for global mental health:

DFID: Where We Are Now

Jane Edmondson described four main areas in which the UK is either directly or indirectly supporting global mental health through Department for International Development (DFID) funding and expertise: (1) research, (2) direct programming, (3) partnerships, and (4) health systems strengthening.

Primary Healthcare Facility, PRIME South Africa

Examples included the PRIME project, a five-country research partnership generating evidence on the integration of mental health into primary care in low-resource settings; BasicNeeds,  which delivers programmes based on an innovative “Mental Health and Development Model” in 11 LMIC in Africa and Asia; and a variety of health partnerships linking UK organizations and funding with organizations in LMIC.

The £20 million Health Partnership Scheme will fund 50 international partnerships over a span of four years (2012-2016). To date, the Scheme has funded six projects with a mental health component in Malawi, Uganda and Ghana. The Butabika Link, a partnership between Butabika Hospital in Kampala, Uganda and the East London National Health Services Foundation Trust, draws on the expertise of the UK’s Ugandan diaspora and exchanges between Uganda and East London-based staff to implement innovative initiatives such as the HeartSounds Peer Support Worker project. Similarly, through a partnership between Ghana’s Ministry of Health and multiple UK institutions, the Kintampo Project has trained and supported two new cadres of mental health workers to address Ghana’s human resource gaps.

Edmondson also pointed out that humanitarian organisations with UK funding such as Médecins Sans Frontières often deliver mental health support in crisis situations, and that DFID’s advisory role in international health systems strengthening efforts benefits all priority health conditions indirectly.

However, when asked by Lord Ribeiro, Vice Chair of the APPG on Global Health, “What proportion of DFID’s spending is actually allocated to mental health in the global setting?” she revealed:

“We don’t have an allocation for mental health within our resources. We don’t allocate resources in that way, mainly because...we cover it largely through our health systems strengthening.”

Moving Forward: Integration, Implementation and Innovation

Representing diverse perspectives in policy, research and programming, the remaining panellists described a variety of ways in which mental health could be improved in LMIC; however, three key themes were interwoven throughout the discussion.

Integration in policy, integration in practice

Rachel Jenkins drew from her years of experience as a psychiatrist, epidemiologist, and policy-maker to highlight the systematic “institutionalized discrimination" that keeps mental health out of health policy, budgets, and agendas around the world. Isolated efforts by mental health stakeholders won’t work, she argued:

“It’s not enough for us to have mental health policies. We need to have mental health at every level of health policy, because the people who need to read them [mental health policies] don’t.”

Her main message emphasised integration: mental health should be a part of health policy and services at every level of the health system and beyond, as “mental health isn’t just an issue for the health sector, it’s an issue for all sectors.”

Bedbug infested bed in Africa. Image courtesy Dr Rachel Jenkins

By promoting an integrated health systems approach and advocating for universal health coverage in the UK and internationally, we can improve access to comprehensive care that addresses the multifaceted needs of some of the worlds’ most disadvantaged populations.

Ken Grant from HLSP voiced his agreement: “If Rachel’s point was picked up, that mental health was taken as a part of primary care, then that would make a real difference.” He added that the UK should be encouraging governments to take into account disability, not just mortality, when setting priorities for action, and that integrating mental health into primary care would help to ensure that mental health isn’t side-lined.

Panel members also agreed that in the numbers game of international development and policy, better data needs to be routinely available on mental health. According to Jenkins, this means ensuring mental health indicators are routinely collected, integrated into health information systems, and used to monitor the quality of services. However, as Jenkins has described in a previous article, this isn’t as easy as it sounds.

Investing in implementation

Building health information systems isn’t the only challenge faced by implementers. Chris Underhill from BasicNeeds highlighted the need to “fund more practical action on the ground”. While research is important, more opportunities are needed to generate learning on how to provide quality services in low-resource settings—and this kind of learning can only be achieved by doing.

Underhill suggested that stronger coalitions and communities of practice can help promote knowledge exchange and dissemination of best practices, calling for a “global alliance of mental health practitioners”. He also cited progress by the Movement for Global Mental Health and the Mental Health and Psychosocial Support Network in providing information and resources to the global mental health community.

Mary DeSilva from the Centre for Global Mental Health, in a follow-up question to the panelists, described her high hopes for the new Mental Health Innovation Network as an online platform for sharing best practice and building the sort of alliance described by Underhill.

Innovative approaches to quality care

Members of the audience emphasized that the UK’s role should not be to replicate its own mental health system abroad. As a service user representative noted, cultural differences may result in very different understandings of what mental illness is and how it should be treated. Pointing out common complaints of biomedical models of care, he drew from over two decades’ experience accessing ineffective treatment in the UK before finding relief in group therapy in his late thirties.

Community volunteer visits person with mental health problem and carer in Uganda. Image courtesy BasicNeeds

Underhill added that culture should not be used as an excuse for inaction:

“Respecting cultural differences is important, but we also have a responsibility to support people who do want treatment.”

Underhill pointed out that BasicNeeds takes a “whole person” approach, and hires only local teams to design and run in-country mental health programmes.

Victor Doku, a Ghanaian Psychiatrist and Epidemiologist working in London, highlighted the diaspora working within the NHS as a rich, largely untapped resource that the UK should harness. His own charity, Mental Health Educators in the Diaspora was established ten years ago to provide cross-cultural expertise and support to mental health programmes in West Africa.

A variety of psychosocial interventions were suggested as targets for further investment in research and implementation in order to “turn the world upside down”, providing opportunities for the UK to learn from successful efforts in LMIC. Peer-to-peer, self-help, and group therapy interventions were championed as innovative components of care that should be fostered in the community and through primary care. Jenkins also reminded the panel of the need to engage traditional healers, referring to a randomized control trial promoting collaboration between traditional and biomedical practitioners in Ghana, Kenya and Nigeria: “It’s surprising just how common understanding of mental health issues can be.”

However, as a psychiatrist working in Malawi and Uganda pointed out, some people do need specialist care, and this should be available “in a setting of respect and dignity”. Strengthening community care and integrating mental health into primary care are important, but the state of many secondary and tertiary facilities in LMIC is deplorable, and cannot be forgotten.

A “United Front” for the United Kingdom

It is easy to become overwhelmed by the variety of perspectives, experiences and approaches represented in a session like this, intended to define the UK’s role in addressing the “whole person” needs of over 900 million people living with mental health problems around the world.

In his closing remarks, Lord Nigel Crisp picked out integration as perhaps the most prominent theme from the discussion:

“If something’s hidden away, you don’t think about it, and I think we are still in this state, aren’t we? Where mental health is… only 'other business' on the agenda too often, rather than firmly in governments’ minds, NGOs’ minds, and DFID's mind as being fully integrated… and I think that’s the biggest message I can take away from this conversation.”

However, Lord Crisp added, “that’s a message that has a lot of subtleties”. In this session, integration wasn’t limited to the incorporation of mental health services into mainstream healthcare. Integration means tackling global mental health as part of a broad effort to improve health worldwide, by building coalitions across diverse sectors, addressing the multidimensional needs of people affected by mental health problems, and providing quality care with a focus on health systems strengthening.

To this end, Chris Underhill called for a “United Front” for the United Kingdom—better collaboration and more effective partnerships to ensure that we don’t become so involved in our own sporadic efforts that we forget the bigger picture.

A report will be issued in the coming months to advise UK policy on global mental health, following further consultation with experts in the UK and in the field. In the meantime, Underhill’s point may be the more important take-away for those of us working in global mental health. Whether or not DFID is provided further remit to prioritize mental, neurological and substance use disorders in its spending, a “United Front” will allow us to do the most with the resources we have.

As Lord Ribeiro concluded, money isn’t the only thing at stake in these sessions. “We need collaborative efforts. We should see these meetings as opportunities.”

Read the BasicNeeds blog entry for a short summary of this session, and follow APPG Global Health for updates.

Main image: © 2013 Subho Dasgupta, Courtesy of Photoshare

Policy and legislation
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