Abstract
Background:
The burden of disease related to mental disorders across the world is substantial. However, there remains inequality between funding for clinical and research activities between physical illness and mental illness in almost all countries.
Aims:
One way of reducing this inequality is to ensure that mental health policies reflect this. We were interested in looking at the policies of members of Commonwealth.
Method:
We decided to survey 52 member countries of the Commonwealth to explore whether mental health policies existed and whether there was equity between physical and mental health services funding. Using World Health Organization (WHO) data sets and other sources when indicated, we looked at the existence and contents of mental health policies.
Results:
We found that less than half of the countries had a mental health policy. Deinstitutionalization was not seen as a priority in many countries and there was no equity between physical and mental health funding. Although integration between physical and mental health care was recommended in many countries, there was a clear gap.
Conclusion:
It is apparent that there is still a long way to go in terms of equity between physical and mental health in terms of funding in member states of the Commonwealth. These findings confirm earlier observations of discrimination against people with mental illness. We suggest that there must be mechanisms in place to facilitate and support change wherever required.
Introduction
There is no doubt that mental illness is ubiquitous although the forms of presentation and help seeking may vary as these are very strongly affected by the healthcare systems and explanatory models patients and their families follow. Delivery of health care is strongly influenced by availability of human and financial resources. Physical and emotional accessibility of services also plays a role in facilitating pathways into specialist care.
The large global burden of mental health conditions (Whiteford, Ferrari, Degenhardt, Feigin, & Vos, 2015) has led to an increased emphasis on improving access to mental health services in countries across the world. There is a clear recognition that improving mental health governance is key to improving access to and quality of mental health services, and the existence of a mental health policy is an important component of improving mental health governance (World Health Organization (WHO), 2013a). WHO’s Mental Health Atlas 2014 found that 68% of countries had a mental health policy (WHO, 2015), while the WHO’s Mental Health Action Plan 2013–2020 has set a target that 80% of countries should have developed or updated their mental health policies/plans in line with international and regional human rights instruments by 2020 (WHO, 2013b).
The Commonwealth is a voluntary association of 52 independent and sovereign states part of the erstwhile British Empire who, despite their geographical variations, generally have similar political, legal and governance systems. The Commonwealth has an emphasis on democracy and development and supports various activities through the Commonwealth Foundation to promote the Commonwealth’s values and priorities.
We reviewed the mental health policies of Commonwealth countries with the following aims: (a) to identify mental health policies and compare them to standards for mental health policy developed by the WHO and (b) to assess compliance of these mental health policies with international recommendations.
Methods
We identified and downloaded mental health policies of Commonwealth countries from WHO Mindbank, an online repository of national and regional level policies, strategies, laws and service standards for mental health, substance abuse, disability, general health, non-communicable diseases (NCDs), human rights and development, children and youth, and older persons (WHO Mindbank, 2017).
If mental health policy was not found on WHO Mindbank, we extended our search to official government websites of countries. In the case of federal countries, such as Canada and Australia, we relied on a federal mental health policy and, if this was absent, we used the most recent mental health policy from any of the provinces or if there were two policies from the same year, the mental health policy from the province with the larger population.
We used WHO’s (2017) mental health policy checklist to assess compliance of country mental health policies with international recommendations. This checklist is a useful tool to evaluate whether certain processes have been followed that are likely to lead to success of the policy, whether specific content issues have been addressed and appropriate actions are included in the policy.
The checklist uses three different levels to rate each item ranging from ‘1 = yes/to a great degree’, ‘2 = to some extent’ and ‘3 = no/not at all’. A rating of 4 is assigned for ‘unknown’ items. In accordance with previous studies, we did not use the ‘unknown’ rating as we relied only on what is written into the policy and if something was not mentioned in the policy, rated it as ‘no/not at all’.
Results
A total of 11 countries did not have a mental health policy. We were unable to find a mental health policy from 16 countries, although we found references in different documents to a mental health policy. We found a mental health policy from 25 countries (48%), of which Naaru and Zambia had a ‘final draft’ policy and Uganda and St Lucia had a draft policy, which were all included in the analysis.
Only seven (25%) countries had a mental health policy adopted after 2011 (Table 1). In only two (8%), mental health policies contained an explicit reference to country data and research informing policy development (Table 2).
Income level of the countries (World Bank classification) and year of mental health policy.
Has relevant research been undertaken to inform policy development (e.g. pilot studies)?
In total, 24 policies (96%) had a realistic vision statement and 20 policies (80%) had statements on values and principles which informed the policy.
While 15 policies (60%) indicated how funding would be used for financing of equitable mental health services, only four policies (16%) had a clear statement on providing equitable funding between mental health and physical health and only five policies (20%) explicitly stated that mental health should be included in health insurance (see Table 3).
Financing.
Seventeen policies (68%) promoted human rights and only 14 policies (56%) specifically mentioned developing human rights–oriented mental health legislation (see Table 4).
Human rights.
Only one policy (4%) had detailed intersectoral collaboration outlined, while four policies (16%) had it to some extent. Only two policies (8%) contained clear statements of the role of each department in different areas of action as illustrated in Table 5.
Intersectoral collaboration.
A total of 14 policies (56%) included a process to measure and improve the quality of mental health services (see Table 6).
Quality improvement.
Only three policies (12%) either significantly or to some extent made a commitment to putting in place suitable working conditions for mental health providers. Twenty-one policies (84%) did, however, recognize that training in core competencies and skills was important for human resource development (Table 7).
Human resources and training.
In total, 14 policies (56%) promoted integration of mental health services into general health services but surprisingly only 11 policies (44%) promoted deinstitutionalization (Table 8).
Organization of services.
Nearly half of the policies had provisions for promotion, prevention of mental disorders and rehabilitation of persons with mental illness (Table 9).
Prevention, promotion and rehabilitation.
Worryingly only half of the policies emphasized the need for research and evaluation of services and evaluation of the policy and strategic plan. (Table 10)
Research and evaluation.
Discussion
While WHO reported that 68% of countries globally had a mental health policy, we were only able to find a mental health policy for 48% of Commonwealth countries, which is significantly below the global average. Most (92%) of the Commonwealth mental health policies were old and adopted prior to 2011. Thus, the Commonwealth countries were behind the global average with the WHO Atlas reporting that 47% of countries globally had adopted a mental health policy after 2010 (WHO, 2015). There are possibly many reasons for the lack of mental health policies and older mental health policies still in existence in Commonwealth countries including failure of mental health sector to advocate effectively, lack of technical skills in mental health policy development and limited political interest due to stigma and discrimination itself thereby setting up a vicious circle. The existence of older mental health policies in Commonwealth countries also means these policies may not be compliant with countries’ current international human rights obligations for example under the United Nations Convention on Rights of Persons with Disabilities.
Financing of mental health remains a concern as resources are often inadequate in most countries. Worldwide, low-income countries spend 0.5% of their health budgets on mental health while the corresponding figures are 1.9% for lower middle–income countries, 2.4% for upper middle–income countries and 5.1% for high-income countries (WHO, 2013a). There is no reason to believe that these figures are significantly different in Commonwealth countries. Although 60% of policies recognized the role of funding in equitable mental health services, only a tiny minority of policies explicitly addressed equitable funding between services for mental health and physical health.
We know anecdotally that in many countries health insurance from private insurance providers (and at times public insurance providers too) excludes treatment of mental illness. It is a matter of serious concern that policies in only a fifth of the countries specifically have a commitment to including mental health in general health insurance. A mental health policy offers a chance to challenge and address systematic institutional discrimination and disadvantage faced by mental health services and persons with mental illness. Policymakers and mental health stakeholders in Commonwealth countries have sometimes missed a significant opportunity to address funding disparities for mental health and ensuring equity with physical health.
WHO’s Mental Health Action Plan sets a global target for 50% of countries to develop or update their mental health legislation in line with international human rights instruments by 2020 (WHO, 2013a). Although half of the Commonwealth country policies state the development of new mental health legislation as a key policy action (this should be seen as a heartening development at first glance and the WHO global targets should be met to improve outcomes) the reality lies in actual delivery and whether Commonwealth countries which have new legislation as a key policy action do succeed in delivering equity.
It is now well accepted that addressing mental health problems requires intervention across many different sectors including health, social welfare, education, justice, employment to name just a few. It is therefore surprising to note the near total absence of any emphasis on intersectoral collaboration in these policies in Commonwealth countries.
We were also concerned to note that only half of the policies promoted integration of mental health with physical health services, deinstitutionalization, promotion of mental health, prevention of mental disorders and rehabilitation. There is a broad consensus in the mental health sector that actions such as integration with physical health care and deinstitutionalization are essential components of quality mental health service and we were surprised to note that this was not reflected in all the policies. It is important to recognize that in many countries old asylum style institutions are the norm and moving patients and services into communities is fraught with serious risk, adequate planning and resources are needed to deliver this. The lack of emphasis on improving quality of mental health services in the policies in half of the countries is equally disconcerting because it allows poor-quality services to continue without change and perpetuates poor outcomes.
Only 50% of policies included research and evaluation of policies and services indicating a general lack of interest in an important component of future policy development. The absence of systematic evaluation of existing policies for impact may result in ineffective policies and services continuing to be offered and delivered and consequent failure to achieve policy goals.
Limitations
There are two main limitations to our study which is based only on an analysis of written policy documents available through an Internet search. It is possible, though unlikely, that we may have found the mental health policy of 16 countries (where documents refer to a mental health policy) if we had contacted individuals and/or Ministries of Health in those countries. However, WHO Mindbank has collected data from ministries in countries as well as information from professionals and other mental health stakeholders from countries and it is unlikely that they would have also missed out on obtaining copies of these policies. The utility of a mental health policy which is not easily accessible or available is also debatable.
The other important limitation to our study is that we did not analyze how effectively existing policies were implemented in these countries. This is important as countries with mental health policies do not necessarily implement them – WHO Atlas reported that only 15% of countries globally reported that mental health policies were fully implemented (WHO, 2015). We did not look at specific human and financial resources which raise both ethical and moral questions.
Conclusion
Commonwealth countries range from low-income countries to high-income countries with varying population and resources. Our findings indicate that there is still some way to go in bringing about equity between physical and mental health care but also equity between different countries. The informal links between countries indicate the strength of the relationship and perhaps high-income countries need to consider mentoring and supporting low-income countries to ensure that mental health policies are developed appropriately in order to deliver best care which our patients need, deserve and will utilize.
Footnotes
Acknowledgements
An earlier version of this article has been published in World Psychiatry. The authors thank Professor Mario Maj for publishing the summary of the findings.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by the World Psychiatric Association (WPA) while Dinesh Bhugra was the President of the WPA.
