Abstract
The World Health Organisation (WHO, 2021) Mental Health Atlas published every 3 years helps to monitor progress of the WHO Comprehensive Mental Health Action Plan. It reports on mental health policies, legislation, human resources, availability and utilisation of services, financing and data collection systems. The latest Atlas published covers the 2017 to 2020 period. Whilst a small time period in the analysis overlaps with the COVID-19 pandemic, results overall are unlikely to be attributable to the pandemic.
The findings are stark – only one of the six targets set by global leaders has been achieved (reducing suicides by 10% between 2013 and 2020). Unfortunately, none of the targets for effective governance, community-based services, promotion and prevention, financing (investment in mental health remains below 2%) and strengthening of information systems were close to being achieved. When viewed in sum, the Atlas paints a disappointing picture of a worldwide failure to provide people with the adequate mental health services they need.
The WHO approach, in the context of seeking to align the Comprehensive Mental Health Action Plan with the 2030 agenda for sustainable development, has been to extend the Comprehensive Mental Health Action Plan from 2020 to 2030. Despite the extension of 10 years, the ambitions remain the same. At a time when the COVID-19 pandemic is highlighting a growing need for mental health support, is this WHO approach entirely sufficient?
Where should the focus be?
There is a growing global awareness that in addition to social determinants, geopolitical factors such as climate change, pandemics, conflict, natural and manmade disasters, displacement and erosion of human rights play a major role in the mental health and wellbeing of individuals. Geopolitical factors are changing the cultural architecture of community and their psychological security. Greater attention needs to be paid to today’s global multi-dimensional challenges and there is a need to change current global mental health narratives to reflect this.
As countries and leaders grapple with domestic and international political challenges, mental health and wellbeing cannot be advanced with a purely biomedical and technocratic approach. Mental health is deeply enmeshed with wider geopolitical challenges. There is need to resolve challenges related to climate crisis, human trafficking, COVID-19 and equitable access to vaccines, poverty, hunger, economic access, migration and other regional geopolitical events.
Crises across the world are having a huge impact on millions of people’s lives and are fuelling the burden of global poverty. The World Bank Report Poverty and Shared Prosperity 2020 (The World Bank, 2020) estimates COVID-19 to add as many as 150 million more people as ‘extreme poor’ by end of 2021 with 8 out of 10 ‘new poor’ resident in middle-income countries. By 2030, an estimated 80% of the world’s extreme poor will live in fragile states (ECD, 2018). COVID-19 is aggravating insecurity in vulnerable and fragile, countries and territories and is adding to the global burden of displacement as more people move to get out this extreme poverty trap. Current global displacement stands at 85.3 million and this is significantly higher when compared to 65.5 million in 2016 (The United Nation Refugee Agency, 2021).
Existing evidence suggests that countries that have strong democratic institutions and accountability achieve better physical and mental health outcomes (Templin et al., 2021). In recent years, democratic institutions have been weakened with leaders opting to govern autocratically rather than inclusively. The COVID-19 pandemic has thus exacerbated a 15 year decline in democracy, with 35 of the 79 countries and territories that experienced democratic decline thought to be related to the pandemic. When this is considered with the global inequity in vaccine access and distribution, emergence of new variants, there is real likelihood of a prolonged health crisis and related erosion of democratic institutions and accountability (Freedom House, 2021). When considering the presence of mental health specific policy in line with international and regional human rights instruments, the Mental Health Atlas note significant gaps remain with only 51% of countries meeting these criteria. This is concerning when we consider wider literature suggests that certain countries such as Commonwealth countries lag further behind. This underscores the importance of considering geopolitical and historical considerations when considering systems and processes (e.g. colonialism and origins of governance systems; Bhugra et al., 2018).
A renewed approach to tackling systemic challenges
It is time for a new global mental health order and to find a new approach to tackle today’s most stubborn and urgent development challenges. The CAPE Vulnerability Index (Persaud et al., 2020) offers a different perspective to rebalance and challenge prevailing narratives of how foreign aid is utilised. It provides a funding formula where foreign aid could be used as a tool to build mental health into foreign policy (Persaud et al., 2018). Foreign aid must do more than respond to humanitarian crisis. This tool can be used to identify the most vulnerable countries so that international aid may be more appropriately targeted in a well-structured way with mental health as a strong foundation.
Our minds must not lose focus on how the world is changing in the COVID-19 era. It is no longer acceptable to maintain or manage the status quo. Whilst countries are sovereign and make their own health decisions, it is clear that geopolitical determinants of health (Persaud et al., 2021) such as pandemics, climate change and conflict are transnational and require concrete coordinated action with strong global leadership, governance and ethics. Making mental health progress in the face of these large structural and dynamic problems that our world is facing will require dedicated work for a long time but change must happen.
Issues related to poverty, women and children in conflict, COVID-19 pandemic, migration, funding and decolonising the global mental health agenda remain active and important. A renewed approach to tackle geopolitical determinants of mental health is urgently needed to improve the mental health and wellbeing of individuals and communities around the world.
