A rights-based approach to mental health financing
What do James Wheeler, a 57-year-old man from Birmingham, Alabama, and Deborah Phehla, a 46-year old woman from Johannesburg, South Africa have in common? Despite being worlds apart, they were both casualties of mental health systems that failed them.
After seeking help from a local health facility whose mental health services were reportedly under-staffed, Mr. Wheeler was sent home with no support, taking his own life—just hours later. Ms. Phehla, meanwhile, was discharged from a mental health institution into the care of an under-resourced community-based organization, where she died from physical complications because of extreme neglect.
These entirely preventable tragedies illustrate the lack of resources for addressing the needs of people with lived experience of mental health challenges, and underscore the reality of a global problem in need of urgent attention.
While we have seen an increasing interest in prioritizing mental health within the development and health financing landscape—such as in the inclusion of mental health specific language in the United Nations Sustainable Development Goals, and in the World Bank’s efforts to bring mental health ‘Out of the Shadows’—there’s a considerable gap between the rhetoric and the allocation of resources to promote mental health and well-being. According to data from the Organization for Economic Cooperation and Development and the Institute for Health Metrics and Evaluation,1 for example, only one third of one percent of development assistance for health is going to mental health, and some experts say that may even be an underestimation.
This lack of financing is compounded by another concern: mental health initiatives that do get funding do not often meet international human rights norms and standards, as articulated in instruments such as the United Nations Convention on the Rights of Persons with Disabilities (CRPD). Among these standards include the right to receive care and support in one’s community free from coercion and violence; to participate freely and equally in decision making regarding treatment and support; and to live free from the stigma and discrimination that so often characterize the lives of people with lived experience of mental health challenges.
Health systems have traditionally viewed ‘mental illness’ from a purely biomedical lens. This leads to pathologizing in medical and social spheres that may isolate individuals from their communities and deny their agency. We now know that mental health is influenced by psychological, social, cultural, political, legal, economic and biological factors, and any response should be equally multi-faceted. This means that in an ideal world, Mr. Wheeler would have been offered psychosocial support in a community of peers. He would have had access to education about his well-being. And he would have had access to services that might not be traditionally thought of as mental health support but that contribute to his well-being, such as economic opportunities and social protection. Similarly, Ms. Phehla should have had community-based care and support upon discharge that met standards of quality and acceptability and that allowed her to flourish alongside her peers.
Funding and policy-making related to mental health interventions focus on approaches that are purely biomedical, relying heavily on medication as the only form of treatment, and neglecting important psychological and social factors critical for recovery. Stigma and discrimination, even among funders, policy-makers and practitioners, also hinders the development of holistic systems for mental health care and leads to a broad under-prioritization of mental health in policy and financing decisions. Child and adolescent mental health is particularly neglected, and support for the development of culturally competent and contextually appropriate models of care and support is urgently needed.
There is room to be optimistic. Rights-affirming models of mental health care and psychosocial support are beginning to emerge. This is particularly true in the Global South, where there are tangible opportunities to avoid repeating the mistakes of coercive and paternalistic models that have characterized the mental health systems of the Global North, and to build on local best practice that is sensitive to cultural norms which may affect how mental health is understood and supported.
At the Open Society Foundations, we are committed to supporting such initiatives that have the potential to transform the provision of mental health care for the better. We aim to ensure that the historical neglect of mental health is reversed in policy and funding spaces as well as striving to guarantee that mental health initiatives are in line with human rights standards. In doing so, highlighting local knowledge and experiences to advocate for investments in culturally appropriate models of mental health care is a priority.
Increasing global interest in mental health represents an opportune time to address the needs of millions of people whose voices have previously gone unheard. In seeking to meet those needs, however, the global health, development and financing communities will have to ensure that rhetoric is met with action. As Mr. Wheeler and Ms. Phehla’s deaths clearly illustrate, these are critical decisions whose importance cannot be overstated. This moment represents a truly singular opportunity, and one that should not be wasted.
- Charlson, F. J., et al. "Donor Financing of Global Mental Health, 1995—2015: An Assessment of Trends, Channels, and Alignment with the Disease Burden." PloS one 12.1 (2017): e0169384.