Maintaining the Momentum: Out of the Shadows
In April 2016, we had a wonderful two weeks of meetings organized around the World Bank Spring meetings in Washington DC, USA. It was a very invigorating time for the global mental health community, and it underscored just how far the field has come. But we still have far to go, as will be discussed in our launch event for the recently published report ‘Mental Health Funding and the SDGs: What next and who pays?’, taking place next week (21 June) at Family Kingdom Resort, Freetown, in Sierra Leone.
The report was commissioned by the Mental Health Innovation Network (MHIN) and World Health Organisation (WHO), developed by the Research and Policy in Development program of the ODI, and funded by Grand Challenges Canada. It looks at who has funded global mental health in the past and possible future funding sources. The Report had a very well-received London launch on 19th May 2016; this is its regional launch in Africa. We in Sierra Leone are extremely proud to have been approached to carry out this launch. Ministry of Health and Sanitation (MOHS) are preparing the Launch, in partnership with WHO and other partners, such as MHIN, Sierra Leone King’s Health Partnership, IsraAid, The Mental Health Coalition/Building Back Better, and Caritas/Harvard University, among others.
It has taken 20 years of steady and consistent lobbying and advocacy to get mental health ‘at the table’…into the Sustainable Development Goals (SDGs). I joined this community in 1996, when I joined the Ministry of Health of Uganda as the National Mental Health Coordinator. I met wonderful people with a heart and a vision for global mental health, people like Prof Norman Sartorius, Prof Rachel Jenkins, Dr Benedetto Saraceno and Arthur Kleinman, among others. The term ‘Global Mental Health’ had not even been coined.
Over the years, a group of persistent, persevering individuals have, overtly or otherwise, continued to work to get mental health better prioritized in the global health agenda. Among the first efforts was the publication of ‘World Mental Health: Problems and Priorities in Low income Settings'1. I was privileged to be at the launch held in Cape Town, South Africa. This publication, for the first time, brought issues of mental health ‘out of the shadows’ and emphasized its intersection with poverty, war and conflict, and gender, to mention a few. It analyzed mental, behavioural, and social problems in low-income contexts in light of a wider ‘whole-of-society’ perspective.
The struggle to get mental health prioritized has been a long one. Initially, the argument was that mental disorders were not prevalent; various studies had established prevalence to be ~1% for schizophrenia and 5% point prevalence / 20% lifetime prevalence for depression. Since metrics emphasized mortality and the focus was on preventing deaths, the ‘burden’ of mental disorders was perceived to be low. The First Edition of Disease Control Priorities2 and the 1993 World Development Report on Investing in Health3 released the very first disability estimates that considered mental disorders, and they were found to comprise up to 13% of the global disability burden.
This gradually led to an increased recognition of mental health. However, there was still some resistance, with economists not convinced of any economic benefit to providing interventions. At that point, the work on mental health economics had not progressed very far, so investing in mental health services was seen as “pouring money down a drain”; people with mental disorders were seen as unproductive, even after treatment (although there was no evidence for this).
Another challenge was the lack of a model for what mental health systems in low and middle-income countries should look like. It was also not clear what actual mental health services were in place. In 1998, Mr Walter Gulbinat, Prof Rachel Jenkins and Dr Ron Mandersheid convened the “Consortium for Global Mental Health Policy and Services Research,” through which we developed a framework and carried out assessments in a number of low and middle-income countries4-7. The World Health Organization also put out the very first World Mental Health Atlas in 2000.
From this slow but steady beginning, a concerted effort of building up mental health services at a country level begun. WHO encouraged all countries to put in place a National Mental Health Coordinator, separate from the Medical Superintendent of the National Referral Psychiatric Hospital. There was huge resistance from the Medical Superintendents, who felt that their resources would be reduced, not seeing it as an opportunity to actually increase funding to mental health as a whole. Those countries that did initiate this program have made much more progress that those that did not, since resources channeled through psychiatric hospitals do not reach the District/County to develop mental health services.
Probably another process that strengthened mental health services in some countries was decentralization. As governments decentralized, mental health strategies that had been included in the health policy and health sector strategic plan received resources to also decentralize. Additionally, in 2001, the World Health report was focused on Mental Health and recommended integration of mental health into primary health care8.
The next argument was that of cost-effectiveness of services and interventions. The Commission on Macro-Economics and Health included a sub-committee on mental and neurological disorders, and in 2006, the Second Edition of Disease Control Priorities featured a chapter on psychiatric disorders, providing evidence that treatment of depression was more cost-effective than treatment of hypertension, as an example. A package of essential mental health services was also costed. In 2011, the World Economic Forum published a report that put the lens on the cost of lost productivity from untreated mental disorders9.
The culmination of all these activities is that momentum was building; there was increased funding to mental health research, increased funding to mental health research targeting LMICs, and a shift to having mental health researchers from LMICs as Principal Investigators. Research also shifted to include more mental health systems and mental health policy research, strengthening the evidence for implementation science.
However, while we recognized that mental health was cross cutting and integral to the Millennium Development Goals (MDGs), and various journal articles were written to this effect10-11, funding for the MDGs did not consider the role of mental health services in improving their specific indicators. The idea that mental health programs could be funded to improve school performance and retention, or to improve nutrition, education and health outcomes of children of depressed mothers, or to help manage the outcomes of gender based violence, as examples, was not considered.
As the end of the MDG period approached, a group called the FundaMentalSDGs came together to advocate for the inclusion of mental health in the Sustainable Development Goals (SDGs)12-14.’Over ~2 years, we took an organized and consistent approach to this advocacy, including letter writing, meeting with Ministers of Health, attending the UN meetings that were open to civil society, publications, etc. When the first draft of the SDGs did not include the wording we wanted, we intensified the lobbying and advocacy, and eventually did get mental health into the wording for the Health SDG.
This is a huge achievement. To my mind, it has taken over twenty years of staying focused on the one goal to get mental health prioritized at the global level.
Now that we have achieved that, the next step is to ensure we maintain the momentum. This is why this report ‘Mental Health Funding and the SDGs: What next and who pays’ is an important next step. The report looks at who has funded mental health in the past and discusses possible future sources of funding for the various activities that have to be carried out now, in order for the mental health aspects of the SDGs to be achieved. While we have an expectation that multi-lateral and bilateral donors, and maybe even Foundations will increase funding to mental health, the onus is on Governments themselves to prioritize mental health, to put it in budget-lines at National and District/County levels, and to allocate their own resources.
Florence Baingana is the MHPSS Lead at WHO Sierra Leone.
- Desjarlais, R. (1995). World mental health. New York: Oxford University Press.
- Jamison, D. (1993). Disease control priorities in developing countries. New York, N.Y.: Published for the World Bank [by] Oxford University Press.
- World development report 1993. (1993). New York: Published for the World Bank, Oxford University Press.
- Gulbinat, W., Manderscheid, R., Baingana, F., Jenkins, R., Khandelwal, S., Levav, I., Lieh Mak, F., Mayeya, J., Minoletti, A., Mubbashar, M., Srinivasa Murthy, R., Parameshvara Deva, M., Schilder, K., Tomov, T., Baba, A., Townsend, C. and Whiteford, H. (2004). The International Consortium on Mental Health Policy and Services: objectives, design and project implementation. International Review of Psychiatry, 16(1-2), pp.5-17.
- Jenkins, R., Gulbinat, W., Manderscheid, R., Baingana, F., Whiteford, H., Khandelwal, S., Minoletti, A., Mubbashar, M., Srinivasa Murthy, R., Parameshvara Deva, M., Lieh Mak, F., Baba, A., Townsend, C., Harrison, M. and Mohit, A. (2004). The Mental Health Country Profile: background, design and use of a systematic method of appraisal. International Review of Psychiatry, 16(1-2), pp.31-47.
- Schilder, K., Tomov, T., Mladenova, M., Mayeya, J., Jenkins, R., Gulbinat, W., Manderscheid, R., Baingana, F., Whiteford, H., Khandelval, S., Minoletti, A., Mubbashar, M., Srinivasa Murthy, R., Parameshvara Deva, M., Baba, A., Townsend, C. and Sakuta, T. (2004). The appropriateness and use of focus group methodology across international mental health communities. International Review of Psychiatry, 16(1-2), pp.24-30.
- Townsend, C., Whiteford, H., Baingana, F., Gulbinat, W., Jenkins, R., Baba, A., Lieh Mak, F., Manderscheid, R., Mayeya, J., Minoletti, A., Mubbashar, M., Khandelwal, S., Schilder, K., Tomov, T. and Parameshvara Deva, M. (2004). The Mental Health Policy Template: domains and elements for mental health policy formulation. International Review of Psychiatry, 16(1-2), pp.18-23.
- World Health Organisation. (2001). The World Health Report 2001 Mental Health: New understanding, new hope. Geneva: World Health Organization.
- Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A.Z., & Weinstein, C. (2011). The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum.
- Miranda, J. and Patel, V. (2005). Achieving the Millennium Development Goals: Does Mental Health Play a Role?. PLoS Med, 2(10), p.e291.
- Skeen, S., Lund, C., Kleintjes, S., Flisher, A. and The MHaPP Research Programme Consor, (2010). Meeting the Millennium Development Goals in Sub-Saharan Africa: What about mental health?. International Review of Psychiatry, 22(6), pp.624-631.
- Gureje, O. and Thornicroft, G. (2015). Health equity and mental health in post-2015 sustainable development goals. The Lancet Psychiatry, 2(1), pp.12-14.
- Votruba, N., Thornicroft, G., Patel, V. and Summergrad, P. (2015). Strengthening Mental Health in UN’s Sustainable Development Goals. PN, 50(3), pp.1-1.
- Thornicroft, G. and Votruba, N. (2015). Millennium development goals: lessons for global mental health. Epidemiol Psychiatr Sci, 24(05), pp.458-460.