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R. Gater,^1,2 K. Saeed³ and A. Rahman⁴

¹Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, United Kingdom. ²Lancashire Care NHS Foundation Trust, Preston, United Kingdom. ³Mental Health and Substance Abuse Unit, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ⁴ Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom.

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Background

The comprehensive Mental health action plan 2013–2020 was adopted by the World Health Assembly in May 2013 (1). This marked the start of a renewed global 7-year effort “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”. The plan takes an evidence-based, multisectoral approach across the life course and follows the principles of universal health coverage, compliance with human rights and empowerment of persons with mental disorders. It presents a set of actions organized around the 4 objectives, each with 6 targets and indicators. A further 8 service development indicators were incorporated in line with data submitted in response to the questionnaire for the Mental health atlas 2014. These will be used to monitor progress in achieving the objectives of the comprehensive mental health action plan through biennial iterations of the Atlas until 2020.

Building on the experience gained from implementing the action plan for noncommunicable diseases, it was decided that there was a need to put the provisions of the comprehensive mental health action plan into operation. This would be achieved through the development of a regional framework identifying high impact, cost–effective, affordable, feasible strategic actions. These would be supported by a set of indicators to monitor the implementation of the plan.

This paper describes the process followed in the Eastern Mediterranean Region for the development of the regional framework for scaling up action on mental health (2) towards the implementation of the Comprehensive Mental Health Action Plan 2013–2020.

Preparatory phase

The preparatory phase involved progressing further with the concept and identifying the objectives, processes and key stakeholders required to develop the regional framework towards achieving the targets and objectives of the comprehensive mental health action plan. The key stakeholders identified were directors general of health and mental health focal points in the Member States, international and regional experts, experts from partner organizations, relevant staff from country offices, and staff from World Health Organization (WHO) headquarters and the Regional Office for the Eastern Mediterranean.

The specific objectives were to:

develop an analysis of the mental health system resources and capacities in countries of the Region;

develop policy briefs collating the best evidence and practices in specified areas; and

draft a regional framework reflecting cost–effective, affordable, feasible strategic actions, supported by a set of indicators to monitor implementation.

The processes employed to achieve the objectives were detailed into activities with responsible actors, and time plans with deadlines were established for the steps required to attain the objectives (for example, see Table 1 for the analysis of the mental health system resources and capacities in the countries of the Region).

In order to develop policy briefs collating the best evidence and practices, a set of 9 topics were identified by blending the 6 building blocks for strengthening health systems (3) and the 4 objectives of the comprehensive mental health action plan. The topics included: mental health policy and strategic plan, legislation, investing in mental health, reorganization of services from institutional to community-based models of care, human resources, mental health and psychosocial support in humanitarian emergencies, promotion of mental health and prevention of mental disorders, mental health surveillance and information systems, and mental health research.

For each brief, 1 or 2 lead experts were identified, supported by teams of up to 8 contributors and up to 8 reviewers. In all, more than 40 international experts were invited to contribute to preparing or reviewing the evidence briefs. The policy briefs were structured according to a common template with sections addressing the rationale, reviewing the relevant evidence, and making key recommendations for ministries of health in the countries of the Region. Although the evidence briefs were prepared to this standard template, they each had a style and character determined by their individual authors. In order to refine, harmonize and focus the evidence briefs, 2 of the authors (RG and KS) edited them into a standard format starting with a “Why? What? Who?” box and culminating in a clear set of recommendations that summarized the evidence for the strategic actions of the regional framework.

Countries were included in the teams involved in developing the briefs; in particular countries were invited to contribute descriptive case studies included with the briefs to highlight the programmes/interventions conforming to evidence-informed practices.

The regional framework was drafted as a set of strategic actions, accompanied by a set of indicators, and listing the WHO tools for monitoring and facilitating the implementation of the actions so as to realize the vision of the comprehensive mental health action plan. Over the past 3 decades there have been a number of local and regional initiatives to enhance mental health, yet the mental health atlases of 2005 and 2011 have shown that progress to improve mental health provision across the Region has been limited (4–6). Consequently, the formulation of the regional framework has been guided by principles that seek to ensure that its practical implementation can be successfully achieved within the countries of the Eastern Mediterranean Region. In keeping with these guiding principles, the strategic actions and indicators are:

evidence-based: evidence was used to identify “best buys” (7) which have the greatest health benefit, and are cost–effective and affordable, and for which scaling up is feasible, even in countries with limited resources;

clear and specific: broad maxims and general vague advice were avoided;

economical: the number of actions and indicators was kept to a minimum and they were expressed succinctly, avoiding over-complication and giving a clear message;

relevant and feasible: for implementation in the countries of the Region;

consistent: with meeting the goals and objectives of the comprehensive mental health action plan, and they were internally consistent with, and complemented, the other actions within the framework.

The indicators identified in the regional framework were in conformity with the core indicators of the comprehensive mental health action plan, but additional intermediate indicators were included to monitor the progress towards achieving the strategic actions identified in the regional framework.

In addition to the virtual consultations with international experts (described above), the WHO hosted a face-to-face consultation in Cairo in June 2014 between a select group of experts and WHO staff involved in the process in order to refine the concept, evidence briefs and framework.

Engaging key stakeholders

At an early stage Member States and partner organizations were informed about the project and invited to comment and contribute to its development. Throughout the process Member States continued to participate and were encouraged to contribute to successive drafts of the policy briefs and framework. This was carried out by email and telephone, leading up to a face-to-face, high-level, inter-country meeting at the WHO Regional Office for the Eastern Mediterranean in Cairo, 15–17 September 2014. All Member States of the Region were invited to participate in this meeting to review, refine and confirm commitment to the regional framework.

Confirming agreement with stakeholders on the framework

The September 2014 meeting was attended by mental health focal points from Member States and a select group of international experts who had been closely involved in preparing the evidence briefs to guide the regional framework. The Regional Director urged delegates to produce a practical and realistic agenda for action, focusing on high-impact issues that would be useful to policy-makers. Delegates reviewed the current situational analysis (8) and evidence briefs, and refined the regional framework through a series of presentations and workshops addressing each of the briefing paper topics [a report of the meeting is included in this theme issue(9)]. Accordingly, the regional framework was modified to make it more relevant and responsive to the issues and priorities raised by the Member States.

Next steps

The next steps were to finalize the regional framework by the end of 2014 by further virtual consultation, and to engage advocacy for its adoption at the highest political level in each country of the Region. Each country has agreed to work on prioritizing the strategic interventions identified in the regional framework and to monitor progress using the proposed set of indicators. The framework will be presented for adoption at the Regional Committee Meeting for the WHO Eastern Mediterranean Region in October 2015.

The regional framework is an important step in the process of implementing the comprehensive mental health action plan, but finalization of the framework is not the end of the process. Implementation will be carefully monitored through future editions of the Mental health atlas and other reviews during the next 6 years, and the framework will continue to be reviewed and revised in the light of progress.

References

1. Mental health action plan 2013–2020. Geneva: World Health Organization; 2013 (http://www.who.int/mental_health/publications/action_plan/en/, accessed 8 April 2015).
2. Proposed regional framework to scale up action on mental health in the Eastern Mediterranean Region. East Mediterr Health J. 2015; 21(7):549–550.
3. Everybody’s business. Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: World Health Organization; 2007 (http://www.who.int/healthsystems/strategy/en/, accessed 7 May 2015).
4. Mental health atlas 2011. Geneva: World Health Organization; 2011 (http://www.who.int/mental_health/publications/mental_health_atlas_2011/en/, accessed 8 April 2015).
5. Mental health atlas 2011: resources for mental health in the Eastern Mediterranean Region. Cairo: World Health Organization; 2013 (EMRO Technical Publications Series 41) (http://applications.emro.who.int/dsaf/emropub_2013_1578.pdf, accessed 8 April 2015).
6. Mental health atlas 2005. Geneva: World Health Organization; 2005 (http://www.who.int/mental_health/evidence/mhatlas05/en/, accessed 8 April 2015).
7. From burden to “best buys”: reducing the economic impact of non-communicable diseases in low- and middle-income countries. Geneva: World Economic Forum and World Health Organization; 2011 (http://www.who.int/nmh/publications/best_buys_summary.pdf, accessed 8 April 2015).
8. Gater R, Chew Z, Saeed K. Situational analysis: preliminary regional review of the Mental Health Atlas 2014. East Mediterr Health J. 2015; 21(7):467–76.
9. WHO events addressing public health priorities. Committing to action: mental health in the Eastern Mediterranean Region. East Mediterr Health J. 2015; 21(7):546–8.