PDF version

S. Saxena,¹ M.K. Funk ¹ and D. Chisholm ¹

¹Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland (Correspondence to M.K. Funk: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

---

Introduction

Twenty years ago, a book was published entitled World mental health: problems and priorities in low-income countries (1). A few years later in 2001, the World Health Organization (WHO) devoted its World Health Report to Mental health: new understanding, new hope (2), and the Institute of Medicine in the United States of America brought out Neurological, psychiatric, and developmental disorders: meeting the challenge in the developing world (3). These publications were among the first to seize upon the finding that, due to their chronic course and disabling nature, mental, neurological and substance use disorders contribute very significantly to the global burden of disease. Each report also drew strong attention to the desperate situation in most low- and middle-income countries regarding the availability, quality and range of treatment services, and produced a series of recommendations for research and training, service provision and policy.

In a number of respects, much progress has been made since then. Awareness and acceptance of the value of mental health and the challenge posed by mental ill-health has continued to grow, both at the international level and in an increasing number of countries. New alliances and partnerships have been formed, including civil society organizations advocating for better rights and service access for persons with mental disorders and their families. In addition, the evidence base around what resources are available in countries and which interventions are effective, feasible and affordable to implement in the context of low- and middle-income countries has improved dramatically (4–7).

In other respects, however, the situation now is not greatly different to how it was 20 years ago. There continues to be widespread stigma, discrimination and human rights violations against persons with mental disorders and psychosocial disabilities (8). Resources allocated to mental health remain extremely modest; the treatment gap is as large as ever (5,9).

This, then, was the backdrop against which a concerted new effort has taken place to put mental health higher on the health and development agenda of countries throughout the world. Culminating in the endorsement of the Comprehensive mental health action plan 2013–2020 in May 2013 by the 194 Member States of WHO (10), this new effort now commits governments, as well as WHO and other partners, to taking defined actions across a number of areas of implementation. This article briefly sets out what these actions are, whose responsibility they are, and how they support the proposed regional framework to scale up action on mental health in the WHO Eastern Mediterranean Region.

Development of the plan

The process started with a proposal by a number of Member States to include an agenda item on mental health at the Executive Board meeting of the WHO in January 2012; this was accepted and led to a Resolution, first at the Executive Board and subsequently at the World Health Assembly (WHA) of that year, on the global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. The WHA Resolution requested the Director-General, inter alia, to develop a comprehensive mental health action plan, in consultation with Member States, covering services, policies, legislation, plans, strategies and programmes.

So began an intensive period of drafting and consultation, not only with WHO Member States but also with nongovernmental organizations, WHO collaborating centres and other academic institutions. A ‘zero’ draft prepared by the WHO Secretariat in the summer of 2012 was made available for comment to all interested parties via a web consultation and was used for global and regional consultation meetings, including in the Eastern Mediterranean Region.

Following revision and its approval by the Executive Board in January 2013, the final draft was submitted to and adopted by the WHA in May 2013.

Key elements of the plan

The Comprehensive mental health action plan 2013–2020 is centred around 4 objectives, all of which are designed to serve the overall goal to ‘promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability for persons with mental disorders’ (10).

The objectives are:

to strengthen effective leadership and governance for mental health;

to provide comprehensive, integrated, responsive mental health and social care services in community-based settings;

to implement strategies for the promotion and prevention in mental health;

to strengthen information systems, evidence and research for mental health.

For each objective, a series of defined actions are identified for Member States, for international and national partners, and for the WHO Secretariat (Table 1). Relating to governance and leadership, for example, proposed actions for Member States cover the development, strengthening and implementation of mental health policies, strategies, programmes, laws and regulations; resource planning; engagement and involvement with all relevant stakeholders; and empowerment of people with mental disorders and psychosocial disabilities.

For each action area, a set of implementation options are also provided, which reflects not only the diversity of current resources and opportunities among countries, but also the different ways by which key actions can be effectively accomplished. Looking across the Member States that comprise the Eastern Mediterranean Region, for example, there are enormous differences with respect to national income, resource availability and the state of the health care system, which is expected to have an important influence on the precise set of actions that can actually be undertaken.

Monitoring implementation of the plan

Each of the 4 objectives is accompanied by 1 or 2 specific targets which provide the basis for measurable collective action and achievement by Member States towards global goals (see Table 1). Since the 6 targets and associated indicators represent only a subset of the information and reporting needs that Member States require to be able to adequately monitor their mental health policies and programmes, the WHO Secretariat was requested to prepare and propose a more complete set of indicators for Member States to use as the basis for routine data collection and reporting to WHO. Additional indicators include:

government health expenditure on mental health;

number of mental health workers;

number and proportion of primary care staff trained in mental health;

extent of participation of associations of persons with mental disorders and family members in service planning and development;

number of mental health care facilities at different levels of service delivery;

number and proportion of admissions for severe mental disorders to inpatient mental health facilities that: a) exceed one year, and b) are involuntary;

number of persons with a severe mental disorder discharged from a mental or general hospital in the last year who were followed up within one month by community-based health services;

number of persons with a severe mental disorder who receive disability payments or income support.

Baseline data collection for this set of core mental health indicators has been undertaken via a revised 2014 version of the Mental health atlas (5). It is anticipated that the Atlas exercise will be repeated periodically, which will enable progress towards implementation of the plan as well as the monitoring of global targets.

Regional and national adaptation of the plan

Agreement on the overall structure and content of a global plan of action, with strong buy-in and consensus across stakeholders, is a vital step towards more coordinated and unified action towards improving mental health system access, quality and outcomes globally. Ultimately, however, policies are determined, resources are allocated and services are developed at the national level. It is, therefore, equally vital that such a global action plan be subject to a process of adaptation to prevailing local circumstances, standards and priorities.

This process has been facilitated by WHO through the development of regional action plans and implementation frameworks, which has enabled groupings of countries with shared cultural values to better reflect their own needs and preferences. Thus, in the Eastern Mediterranean Region, the initial consultation held at the drafting stage of development has been followed by a technical inter-country meeting at which regionally-focused objectives, implementation strategies and performance indicators could be reviewed, discussed and approved by national counterparts. The evidence briefs set out in this Mental Health Supplement were a direct input into these proceedings.

Conclusion

Adoption of the Comprehensive Mental Health Action Plan 2013–2020 by the World Health Assembly in May 2013 provides the clearest example to date of an increasing commitment by governments to enhance the priority given to mental health within their health and public policy (10). The agreement by all countries – large and small, rich and poor, from all regions of the world – on a common vision for mental health along with objectives to reach defined targets within a specified time period represents an important step in a longer process to improve mental health across the world.

References

1. Desjarlais R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. Oxford: Oxford University Press; 1995.
2. World health report: mental health: new understanding, new hope. Geneva: World Health Organization; 2001.
3. Institute of Medicine. Neurological, psychiatric, and developmental disorders: meeting the challenge in the developing world. Washington (DC): National Academy Press; 2001.
4. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva: World Health Organization; 2010.
5. Mental health atlas 2011. Geneva: World Health Organization; 2011.
6. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet. 2007 Sep;370(9590):859–77. PMID:17804063
7. Patel V, Thornicroft G. Packages of care for mental, neurological, and substance use disorders in low- and middle-income countries: PLoS Medicine Series. PLoS Med. 2009 Oct;6(10):e1000160. 10.1371/journal.pmed.1000160 PMID:19806180
8. Drew N, Funk M, Tang S, Lamichhane J, Chávez E, Katontoka S, et al. Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis. Lancet. 2011 Nov 5;378(9803):1664–75. PMID:22008426
9. Lora A, Kohn R, Levav I, McBain R, Morris J, Saxena S. Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bull World Health Organ. 2012 Jan;90(1):47–54, 54A–54B. PMID:22271964
10. Comprehensive mental health action plan 2013–2020. Geneva: World Health Organization; 2013 (apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R8-en.pdf, accessed 13 April 2015).