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Editorial

Ala Alwan ¹ and Khalid Saeed ²

¹Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

²Regional Adviser, Department of Mental Health and Substance Abuse, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

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Mental disorders are common and disabling. At any given time worldwide about 1 person in every 10 is suffering from a mental disorder, and about 1 in 4 families has a member with a mental disorder. Mental, neurological and substance use disorders combined account for a considerable proportion of the disease burden and as much as a fifth of years of life lived with disability. While effective pharmacological and psychosocial treatments are available and can be successfully applied in low-income countries, the vast majority of people with a mental disorder in these countries do not receive treatment (1). The treatment gap, of people who require care but do not receive it, has been estimated to range from 76% to 85%. This gap in provision of care can be attributed not only to lack of resources but also to inefficient allocation of available resources. Globally, most countries spend less than 2% of their health budget on mental health, which typically falls well short of the US$ 3–4 per capita needed for a selective package of cost-effective mental health interventions in low-income countries and the up to US$ 7–9 per capita needed in middle-income countries (1,2).

In the past 2 decades, the World Health Organization (WHO) has increasingly focused attention on action to improve mental health services and to reduce the burden of mental disorders. Key milestones have been the publication of the World Health Report 2001 (3), which for the first time was devoted to mental health; and the launch of the Mental Health Gap Action Programme (mhGAP) in 2008 (4), which aimed to improve effective and humane care for people with mental disorders and to close the wide gap between the treatment that is urgently needed and that which is actually available and delivered.

In May 2013, the World Health Assembly adopted the Global Mental Health Action Plan 2013–2020 (1), which is a commitment by all 194 Member States to take action to improve mental health. The 4 objectives of the plan are “to strengthen effective leadership and governance for mental health; to provide comprehensive, integrated and responsive mental health and social care services in community-based settings; to implement strategies for promotion and prevention in mental health; and to strengthen information systems, evidence and research for mental health.” Each of these objectives is accompanied by actions for Member States, partners and the WHO Secretariat, with defined indicators and targets to be met by 2020.

The WHO Eastern Mediterranean Region (EMR) faces particular challenges in implementing the Global Mental Health Action Plan. It comprises 22 economically diverse countries, with their own cultures and characteristics. A substantial number of these countries have recently experienced insecurity, war and humanitarian crisis. In complex humanitarian situations, not only the rates of mental disorders tend to increase but there is attrition in the capacity of the health and social systems to respond to the increased needs and demands. WHO projects that about 1 in 6 people have a mental disorder after an acute major emergency. Close to 1 in 30 people will have a mental disorder so severe that it undermines their ability to function and survive a chaotic emergency environment (5).

With different countries in the Region being at different stages of development, including the development of their mental health systems, the Regional Office for the Eastern Mediterranean (EMRO) has devised a classification of countries into 3 groups that are similar in terms of their population health outcomes, health system performance and level of health expenditure (6). This facilitates more meaningful comparisons between countries as well as the formulation of recommendations appropriate to each country’s current level of health system and socioeconomic development.

The Mental Health Atlas 2014 is designed to collect information to report on the agreed upon indicators and targets of the Global Mental Health Action Plan (1). The current iteration of the Atlas will provide data on the status of mental health services in countries of the EMR that will serve as a benchmark to monitor progress towards achieving the targets of the global plan. Preliminary analyses suggest that there is a pressing need to initiate and lead a process of change towards these objectives. For example, even though a substantial number of EMR countries have recently published mental health policies, more than half of these are not fully compliant with international human rights instruments and none are fully implemented. Several countries have outdated legislation about mental health, much of which does not conform with international human rights instruments. The involvement of associations of service users and their carers in the formulation and implementation of mental health policies, laws and services is markedly underdeveloped in the Region. Many countries continue to have institutionally-based mental health services, with the majority of staff located in mental hospitals. Across the Region, about two-thirds of mental health beds are in mental hospitals, and this proportion has not changed since the Mental Health Atlas 2011 (7). The mental health workforce is small, especially in the less developed countries, and this has also remained static in most EMR countries over the last 3 years. In some countries, such as some of those with humanitarian crises, the mental health workforce has been further depleted. Only a small minority of primary care staff have received recent training in mental health. One-quarter of countries in the Region have no national mental health or promotion programmes, and half the countries have 3 or fewer such programmes. There is also a scarcity of mental health information and limited research evidence with which to inform service planning or to monitor implementation.

In order to implement the Global Mental Health Action Plan within the Region, EMRO has developed a framework to operationalize the proposed actions by converting them into practical and concrete recommendations for intervention. The field of mental health is often seen as complex and unwieldy, and hence care has been taken to focus the framework on a limited number of priority strategic recommendations grouped under 4 domains mirroring the objectives of the global action plan. The principles guiding the development of the proposed regional framework are: evidence-informed; specific; parsimonious and relevant; and feasible and internally consistent. The framework also incorporates a set of SMART indicators [Specific–Measurable–Achievable –Relevant–Time-based] that will be used to monitor progress towards the global targets for 2020.

In order to inform and support the framework for implementation, EMRO has commissioned teams of international experts to develop evidence briefs on key components of mental health systems. The remit of these briefs is to review and summarize national and international evidence relevant to EMR countries, and to suggest strategic interventions for ministries of health that are affordable, cost-effective and feasible to bridge the treatment gap in countries of the EMR. These briefs, which are brought together in this theme issue of the Eastern Mediterranean Health Journal along with the framework for implementation, represent the current best evidence for mental health interventions for the Member States of the EMR.

The key recommendations include:

reorientation of mental health services from institutional to community-based services;

building the capacity of the mental health workforce to provide community-based integrated care;

revision of mental health policies, plans and legislation conforming to international human rights instruments;

assessment of national mental health resource needs and corresponding prioritization of budgetary allocations, taking care to protect people from the potentially catastrophic costs of mental disorder;

implementation of specified “best buy” interventions within the mental health system and promotion and prevention programmes;

review and decriminalization of the legal status of suicide and self-harm and establishment of suicide reporting at a national level;

embedding mental health and psychosocial support in national emergency preparedness plans;

routine collection and reporting on resources, service availability and coverage for priority mental disorders; and 

enhancing the capacity to carry out priority research to inform policy and service development.

References

1. Mental health action plan 2013–2020. Geneva: World Health Organization; 2013 (http://www.who.int/mental_health/action_plan_2013/bw_version.pdf?ua=1, accessed 27 April 2015).
2. Chisholm D, Saxena S. Cost effectiveness of strategies to combat neuropsychiatric conditions in sub-Saharan Africa and South East Asia: mathematical modelling study. BMJ. 2012 Mar 2;344:e609. PMID:22389339
3. The world health report 2001. Mental health: new understanding, new hope. Geneva: World Health Organization; 2001 (http://www.who.int/whr/2001/en/whr01_en.pdf, accessed 7 April 2015).
4. mhGAP: Mental Health Gap Action Programme. Scaling up care for mental, neurological and substance use disorders. Geneva: World Health Organization; 2008 (http://www.who.int/mental_health/mhgap_final_english.pdf, accessed 7 April 2015).
5. Tol WA, Barbui C, Galappatti A, Silove D, Betancourt TS, Souza R, et al. Mental health and psychosocial support in humanitarian settings: linking practice and research. Lancet. 2011 Oct 29;378(9802):1581–91. PMID:22008428
6. Health systems strengthening in countries of the Eastern Mediterranean Region: challenges, priorities and options for future action. In: Regional Committee for the Eastern Mediterranean, fifty-ninth session, provisional agenda item 3. EM/RC59/Tech.Disc.1. Cairo: WHO Regional Office for the Eastern Mediterranean; 2012 (http://applications.emro.who.int/docs/RC_technical_papers_2012_Tech_Disc_1_14613_EN.pdf, accessed 7 April 2015).
7. Mental health atlas 2011. Resources for mental health in the Eastern Mediterranean Region. Cairo: World Health Organization, Regional Office for the Eastern Mediterranean; 2011 (EMRO Technical Publications Series No. 41) (http://applications.emro.who.int/dsaf/emropub_2013_1578.pdf, accessed 27 April 2015).