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Why Do We Need Mental Health Policy?
Mental disorders are common everywhere in the world and contribute to disability, mortality, loss of economic productivity, and poverty (Murray and Lopez, 1996; Mathers and Loncar, 2006). Across the globe, in both developed and developing countries, mental ill health affects 10–15% of people at any one time, and more in high-risk populations. Mental ill health accounts for 14% of the total global burden of disease (World Health Organization, 2005). Conflict, increasing numbers of refugees, the impact of HIV/AIDS, and nutritional deficiencies contribute further to the burden of mental ill health of those living in poor countries (World Health Organization, 2001a).
Poverty And Education
Poverty and mental health are intertwined and the association reflects causality in both directions: Poverty worsens mental ill health and mental ill health makes poor people poorer. Therefore, the effective provision of mental health services should form an integral part of national poverty reduction as well as general health strategies (Gureje and Jenkins, 2007).
Impact On Children
Parental illness contributes to intellectual and emotional consequences for the next generation.
Impact On Physical Health
The presence of untreated mental disorders also influences the success of prevention and treatment programs for physical illness such as malaria, cholera, HIV/AIDS, tuberculosis, leprosy, and other infectious diseases.
Mental Ill Health Can Be Addressed
Most cases of mental ill health are amenable to cost-effective interventions, whether preventive, therapeutic, or rehabilitative, and can be managed in the community (Institute of Medicine, 2001).
Challenge Of Limited Resources
Delivery of these interventions in resource-poor settings poses significant challenges for health systems, communities, and individuals. Many of the difficulties in delivering effective mental health services reflect generic problems within the health system. Specialist services are limited, and few primary health workers have received adequate training in mental health.
Evolving More Effective And Accessible Services
Most countries in the world are undergoing mental health reform to a greater or lesser extent; the precise nature of those reforms and the current situation in each country are variable. However, the common goal is to achieve comprehensive, local, needs-led, evidence-based, and sustainable care that is in as unrestricted an environment as is compatible with the health and safety of the affected individual, family, and public, tailored to the local context and resources. Many Western countries, and much of Eastern Europe have extensive custodial and institutional care, resulting in impaired health and social outcomes compared to active treatment and rehabilitation in community settings. On the other hand, many low and middle-income countries have very little or no institutional care, but they often also lack adequate access to treatment and rehabilitation in the community. Many countries are also contemplating reform of the legislative framework so that it can support appropriate care in flexible settings, with appropriate attention to human rights.
Both these movements require reform of other areas and, if the public health burden of mental illness is to be tackled effectively, it is necessary for governments to adopt a strategic approach that encompasses all the necessary components ( Jenkins et al., 1998). Most countries focus their policy efforts on the specialist services, but this ignores the problem that the overall mental health-care system is extremely complex, comprising many different agencies that inevitably interact with people with mental illness. The interfaces and patient flows through the system also need to be carefully considered as a blockage in one part of the system will have inevitable consequences for the rest of the system. For example, it is very difficult to resettle people with severe mental illness in the community if stigma surrounding people with mental illness is not tackled through public education and education in schools. Similarly, it is impossible for relatively scarce specialists to focus on those with the greatest need if they are constantly deluged by many referrals of less ill people from primary care. Systems need to be developed so that the most highly trained professionals focus on the most difficult cases, while the front-line health workers address the bulk of mental disorder, in order to achieve access to care for all who need it.
It is important to support governments to adopt mental health policies and to integrate mental health policy into public health policy and general social policy because mental disorder causes a heavy burden for societies, impedes the development of other health and development targets, contributes to poverty, differentially affects the poor, and because mental health itself is of intrinsic value, as is physical health ( Jenkins, 2003).
What Is A Mental Health Policy?
A mental health policy is a written statement of intent by the government on mental health issues and mental health services. Health policy at the national level will identify the range of health, morbidity, disability, and mortality issues it intends to tackle, the relevant settings covered by the policy, the overall framework for implementing policy in the relevant settings, including, for example, health services, social services, the education sector, the workplace, and the criminal justice sector. The policy may set desired goals and will set a framework for planning at local level. The policy document addresses the issues in mental health which require multidisciplinary and intersectoral collaboration at all levels of human development as well as socioeconomic development (World Health Organization, 2001b).
How Can Policy Impact On The Mental Health Of Populations?
Policy, or a mission statement, is required at national and local levels to set broad goals for mental health and the means of achieving those goals. A written National Mental Health Policy is important because it informs the Health Sector Policy Framework, which in turn informs the National Development and Planning Policies.
The policy document can bring all mental health issues into sharp focus and act as an advocacy tool for equitable resource allocation at individual, family, community, national, and international levels.
The policy document can assist in the national allocation of both human and nonhuman resources such as mental health personnel, financing, and supplies and equipment. National mental health policy helps government include mental health into the health and social sector plans so it is not marginalized. It informs the process of mental health legislation. It is a key pillar for the development of national mental health program of action and mental health service delivery in an integrated decentralized manner (including coprogramming with programs for HIV, malaria, other infectious diseases, reproductive health, and child health). A policy is capable of bringing mental health priorities to the same level as physical health and social well-being and of addressing issues of stigmatization, not just within the general population but also within policy makers and professionals. It can help raise awareness in other government departments.
Mental health policy must be integrated with the over- all national health policy, including the general health sector reform strategy, package of essential health interventions, essential medicine kit, health information systems, curricula for all health workers, and country-level work on global burden of disease. The policy must form part of government policy; budgetary and public expenditure processes contribute to the national poverty reduction strategy and involve ministries of finance, education, social welfare, domestic affairs/criminal justice, and employment ( Jenkins et al., 2002).
The Need For Locally Tailored Solutions
Mental health policy will need to take into account the contextual factors, the epidemiology (range, severity, frequency, and duration) of disorders, their accompanying social disability, their mortality, and the relationship to sociodemographic variables, including geographic variation. Epidemiology is fundamental to the overall goals of mental health policy. A few countries are embarking on a specific rolling program of detailed national mental health surveys (e.g., Jenkins and Melzer, 2003) and WHO is coordinating a world mental health survey program in a variety of participating countries (Ustun and Kessler, 2002).
Cultural and religious issues are also very important. They influence the value placed by society on mental health, the presentation of symptoms, illness behavior, access to services, pathways through care, the way individuals and families manage illness, the way the community responds to illness, the degree of acceptance and support experienced on the one hand, and the degree of stigma and discrimination, on the other hand, experienced by the person with mental illness. Each country has a unique context, culture, resources, and existing service structures and each will require its own mental health strategy containing locally tailored solutions ( Jenkins et al., 2004; Jenkins, 2007).
Common Policy Aims
While each country has special needs, problems, resource constraints, and challenges, there are nevertheless some consistent areas that national policy needs to address ( Jenkins et al., 2002). The overall goals of public policy on mental health generally include some or all of the following:
- To promote mental health;
- To prevent mental and neurological disorders;
- To improve the health and social functioning of people with mental illness;
- To deliver appropriate services for early detection, care, treatment, and rehabilitation;
- To reduce the premature mortality of people with mental disorders;
- To reduce stigma;
- To protect the human rights and dignity of people with mental illness;
- To promote the psychological aspects of general health care;
- To engage in appropriate development of human resources;
- To develop a program of research to support the above aims.
Common Policy Components
The components of an effective mental health policy include:
- National components:
- The construction of a national strategy to promote mental health, reduce morbidity, and reduce mortality;
- The establishment of policy links with other government departments including home affairs, criminal justice, education, housing, and finance;
- The enaction of specific mental health legislation to set the overall philosophy of the approach to care of people with mental disorders, together with precise provision for assessment and treatment without consent under certain defined conditions in the interests of the individual and the public, with regard to safeguarding human rights;
- Financing, to remove perverse incentives, to ensure sustainable local financing, and develop funding streams for disseminating good practice models. In all countries, especially poor ones, finance is a major limiting factor and prioritization of services will be necessary. A basic package should include the provision of medicines for patients at primary care level with psychosis, epilepsy, and severe depression; the ability to refer very ill patients for hospital admission; primary care workers supported by specialists in the community; mental health promotion in the community, and intersectoral linkages;
- Implementation plans and a system of accountability and governance.
- Supportive infrastructure components:
- A human resources strategy;
- A consumer involvement strategy;
- A research and development strategy;
- A mental health information strategy (which should include context, needs, inputs, processes, and outcomes; information systems provide an essential resource for clinicians, managers, planners, and policy makers and allows the audit cycle to proceed; users and care providers also require relevant information, and the general public requires information for public accountability);
- Service components:
- Primary care and specialist care, with the links between the two;
- Good practice guidelines;
- Liaison with NGOs, police, prisons, and the social sector;
- Dialogue with traditional healers;
- Mental health promotion in schools, workplaces, and the community;
- Addressing needs of refugees and internally displaced people;
- Disaster preparedness.
The Construction Of A National Strategy
The first step in getting mental health into national policy is to identify and engage key agencies and stakeholders in the overall process so that there is shared ownership of the vision and its implementation. The next step is to undertake a detailed situation appraisal to obtain a good understanding of the context, needs, demands, current policy, service inputs, processes, and outcomes; this is best done in collaboration with key sectors and stakeholders. The third activity is to develop an overall mission statement, set goals and targets, including detailed recommendations on structures to support integrated coordination, liaison, and implementation. The fourth step is to develop strategic plans and implementation frameworks with those agencies that take the local situation into account and that specifically tackle local issues, constraints, and disincentives. The fifth and final step is to review progress regularly using a variety of outcome measures and to fine-tune strategy and implementation.
The policy document should be developed in a democratic and equitable manner with all the stakeholders involved at all stages of its development as well as its implementation.
Policy Partnerships Outside The Health Sector
Inadequate education contributes to social exclusion because of the increased subsequent difficulties in finding work and in participating fully in other social roles. People with poor educational attainment are overrepresented in prisons and in specialized hospitals; they are overrepresented in prisoners with psychological disorder.
Besides their primary educational role, schools are important settings for mental health promotion in order to teach children important life skills aimed at reducing acute and chronic social stresses and enhancing social supports, all of which have a direct influence on mental health.
Policy needs to ensure that the general health education program, which is likely to have already established good links to schools, the media, and health-care workers, now develop and include education of the community on mental health and mental illness, life skills and coping strategies, and responsible community attitudes to people with a mental or physical disability.
The curriculum needs to include education on mental health as part of its health and social skills element and to develop the higher education appropriate for the country’s needs, including generic courses, vocational qualifications, distance learning, and occupational standards.
Children often receive too little policy attention. Specific learning difficulties, including dyslexia in schools, lead to educational failure, dropping out of school, and unemployment, as well as overrepresentation in prisons. It is therefore important for policy to address specific learning difficulties in schools. Provision of spectacles to schoolchildren increases performance, and reduces dropout rates and entry into child labor and child prostitution.
Children Not In A Home Setting
Large numbers of children across the world are looked after in orphanages and children’s homes, which often contain children who have been abused and neglected, children whose home life has broken down, children with developmental delay and retardation, speech delay, seizures, severe hyperactivity and aggression, chronic physical illness, and disability. It should be an important policy imperative to ensure adequate mental and physical health promotion and care to children not in their home setting and to prevent their subsequent overrepresentation in prisons.
To be effective, mental health policy needs to provide a framework for health staff and police to cooperate to ensure that people with mental illness who come into contact with the police receive speedy assessment and treatment. Police may be helpful in bringing acutely disturbed patients to the attention of the health service. However, it is not acceptable for people with mental illness to spend long periods in a police cell. There needs to be liaison, leadership, and agreement at a senior level between the ministry responsible for the police and the Ministry of Health. This needs to provide a framework for liaison between primary care teams, outpatient clinics or outreach teams, and the police. Education and the establishment of agreed procedures for police officers are important.
Mental illness is very common in prisons, and in some Western countries suicide is very high among prisoners. We need systems to prevent and treat anxiety and depression in prison, ensure people with psychosis are treated in hospital rather than prison, prevent suicide and suicide attempts, and tackle dyslexia and educational failure in prisoners.
Mental health policy needs to address the principles and mechanisms of diversion of mentally disordered offenders from the criminal justice system into the health-care system and the implications of this for specialist services. Offenders with less severe mental disorders will need to receive treatment while in prison, and therefore liaison with and education of prison staff on depression and management of suicide risk is important.
Work, unemployment, and specific conditions at work have been shown to have a considerable influence on mental health and mental illness and utilization of mental health services. Rates of illness are higher in the unemployed than in the working population. There is evidence from longitudinal studies that both unemployment, actual redundancy itself, and the threat of redundancy causes mental illness, although it is also true that people who are already ill are more likely to become either voluntarily or involuntarily unemployed.
Workplaces are also a key environment for mental health promotion as well as physical health promotion. Employers bear the cost of the consequences of untreated mental illness in terms of sickness absence, labor turnover, accidents, and poor performance. Employers should therefore be encouraged to include mental health in their workplace health policies, as well as drugs, alcohol, and HIV/AIDS.
Ministries covering employment, trade, and industry therefore need to consider environmental conditions at work; access to employment for all, including sheltered employment for those who need it; opportunities for employment rehabilitation; the introduction of workplace mental health policies, and the provision of occupational health for the workforce in order to support a successful economy and to make an appropriate contribution to the prevention of discrimination against people with mental illness.
Housing And Overcrowding
Crowding has been conceptualized as two distinct but interrelated concepts: Excess stimulation and lack of privacy. Culture defines what is perceived as excessive demands and responses, with differences not only between cultures and countries but also between generations. There is a strong relationship between internal housing density and psychological symptoms in women experiencing very low as well as high levels of density.
Children seem more vulnerable to the effects of crowding than adults, and there is a relationship between large family size and delinquency, low verbal IQ , and poor reading skills.
Homelessness is generally associated with much higher levels of both severe mental illness and depression and anxiety.
There is a consistent tendency across different counties for rates of mental illness to be higher in urban than rural areas, although not all studies find differences. In adults in the UK, urban areas have higher rates of psychiatric morbidity, alcohol dependence, and drug dependence than rural areas, with semi-rural areas in between. Most of the factors differentiating urban from rural areas include higher rates of acute life events and chronic social stresses, less social support, and more mobility in urban areas. In addition, there is a tendency for people with severe mental illness to drift to the cities, where they are overrepresented among the homeless, those living in shanty towns, and other marginalized groups.
Therefore, ministries responsible for the environment and housing will need to consider the impact of its planning decisions on the mental as well as the physical health of the population and to consider the needs for sheltered housing for people with severe mental illness if they cannot live with their families.
Another key urban–rural issue is the fact that in low-income countries, and indeed often in richer ones, most psychiatrists and psychiatric beds are in the large cities, greatly limiting access to specialist care for those in rural areas, and where those from rural areas do manage to access urban services, the large distances involved exacerbate institutionalization and difficulty in rehabilitating the patient back home. These issues are addressed further in the section titled ‘Key Service Provision Issues.’
Key Cross-Cutting Issues
Human Resource Development
Countries need a sustainable human resources strategy to carry out the implementation of policy and the delivery of services. Low-income countries will have difficulty in meeting all their training requirements for health and social-care professionals. They will therefore need a sustainable plan for production and continuing development both at home and elsewhere, of primary and secondary care staff.
The views of service users and care providers will be particularly important, as they will be directly affected by the strategy and will have personal experience of the problems in the current system (e.g., Mirza et al., 2006). They will also be able to comment on those aspects of the current mental health system that are working well. User involvement is one of the great innovations in mental health and provides a framework for placing people who use mental health services at the center of decisions and activities that affect them. It is important to extend the principle of user involvement from users of specialist services to users of primary care services and also to the other sectors besides health that are key for mental health such as schools, universities, prisons, and institutional care of children and the elderly. User involvement is not simply an add-on to existing ways of doing things. Neither is it simply a process of consultation by those in power or authority. Rather it presents a challenge to everyone involved in mental health to reflect and rethink on how traditionally excluded people and groups can be empowered and included in society. People with mental illness, their care providers, and the community are the customers of mental health services. Their involvement can greatly improve the planning and delivery of services since they can spot gaps and problems as well as comment on what is working well. Government pump priming of a national mental health NGO can be a cost-effective way of encouraging progress.
Research And Development
All countries need to establish a sustainable research and development strategy to support its policy development and implementation program. Epidemiology and mental health economics are particularly important contributors to policy and planning. Poor countries cannot meet all their research needs and will have to rely largely on research produced elsewhere; however, there are some crucial questions that can only be answered by local research and this should be planned for.
Policy makers need both qualitative and quantitative information. Qualitative information is just as important as quantitative information and indeed quantitative information will frequently not be available. Policy makers therefore have the task of obtaining qualitative and quantitative evidence from a variety of sources – including research, audit, routine data, user and professional groups, and the general public – and of integrating very disparate bits of evidence, knowledge, experience, and values into a reasonably cohesive whole.
Policy makers need both broad and narrow information on which to base their decisions. Evidence covering contextual issues, needs, service inputs, human resources, service processes and health, and social and economic outcomes is required for policy making. Broad information helps inform decisions such as how much money should be spent overall and how it should be divided between promotion, prevention, treatment, and rehabilitation services. It also helps decide the balances that should be sought between public and private health care, generalist and specialist health care, and mental health care and social care. Finally, it helps determine the importance of public policy on mental health. In contrast, narrow information helps inform decisions on specific treatment options and interventions ( Jenkins et al., 2007).
There are rarely any studies available on which to base broad information decision-making; useful information that can be shared between countries is urgently needed. The systematic review is the narrow information instrument of choice to guide decision making that has proved very useful. However, the quality of the systematic review is entirely dependent on the quality and quantity of the existing investigations on which it is based, and high-quality investigations aimed at issues relevant to the proposed policy are not always available, especially in middle and low-income countries. Only a very restricted set of policy questions have been addressed by systematic review and as soon as one looks beyond the specific to broader health care and the interplay of health care, welfare, criminal justice, education, and environmental policies, experimental trials become difficult or impossible. Given these circumstances, there are a number of steps we can take to improve mental health policy making.
A fundamental tenet of the evidence-based approach is that strong evidence of effectiveness should be established before a practice is adopted. It has generally been assumed that where possible strong evidence comes from randomized controlled evaluations. However, the RCT approach does not always lend itself to key problems, and other approaches also have much to offer and are also valid. Arguably, therefore, government policies should, wherever possible, be subject to the principle of being evidence based.
Health Management Information Systems
Good information is essential within countries to ensure effective planning, budgeting, and documentation of outcomes of resource expenditure. It is therefore important to collect routine data for mental health on:
- Population needs;
- Primary care consultation rates;
- Primary care treatments and outcomes;
- Referrals to specialist care;
- Specialist treatment and outcomes;
- Suicide rates.
Such data can be collected by a combination of household surveys, mortality records, and routine consultation data at primary and secondary care levels.
In addition, more detailed information on country context, needs, resources, provision, and outcome can be collated and compared between countries (e.g., Jenkins, 2004a; Jenkins et al., 2004, 2007). Mental Health Policy 399
Each country needs a legal framework that balances the need and desire of professionals to treat people when they are unable to consent with the need for legal protection of the individual’s rights and regulation of the circumstances in which involuntary detention and treatment can take place. Governments should also develop legislation on disability, antidiscrimination, and welfare benefits.
Addressing Stigma Within A Policy Framework
In developing mental health policy, it is important to include consideration of stigma about mental health issues and mental illness. As well as the impact on the individual with mental illness, stigma results in a lack of attention from ministers and the public, which then results in a lack of resources and morale, decaying institutions, lack of leadership, inadequate information systems, inadequate legislation, and inadequate attention to key public health committees. By resulting in social exclusion of people with mental illness, stigma is detrimental not just to people with mental illness, but also to the health of society as a whole. All too often, our services are departure points for exclusion when they should be stepping stones for social inclusion. The development of civil society, greater local democracy, and local institutional frameworks for the expression of the plurality of views in mental health provides the impetus for more transparency in the creation and evaluation of policy options. As the policy process becomes more open and local, it may gain greater legitimacy for particular policies. As the agenda of public action in mental health increasingly includes the issues of citizenship and human rights, mental health becomes part of the wider human development agenda.
Policy Partnerships Within The Health Sector
Partnerships With Generic Health Policy
Mental health policy needs to be linked to generic health policy. It is particularly important that any general public health strategy address mental as well as physical health so that national mortality indicators include death from suicide and relevant measures of morbidity due to mental illness, and health impact assessments must explicitly include mental health. Some of the generic health policy issues that will impact on mental health include primary care funding, training and incentive arrangements, and government generic health targets.
An effective policy will see mental health included in generic health reforms such as development of health information systems, because it is important to develop the facilities and instruments for routine monitoring of needs, inputs, processes, and outcomes for planning purposes, hospital optimization programs, quality standards, basic training standards, and accreditation procedures.
Governments need to ensure that all relevant agencies are aware of the importance of mental health for the population, that they are aware of the influence that their activities can have on mental health and that appropriate coordination between relevant agencies takes place. This coordination is often in place for action on alcohol and drugs and for AIDS programs but is as yet rarely in place for mental health programs despite mental illness forming the greater burden across the population.
Partnerships With Other Health Programs On Communicable And Noncommunicable Disease
There is a need for a partnership rather than a competition for resources between those working on noncommunicable diseases and infectious diseases. For example, mental health promotion is essential in schools if we are to reduce the risk of AIDS from unprotected sex and drugs and support girls in being assertive and confident in ensuring their sexual health and safety, and if we are to address the lack of acceptance of condoms in the male culture. It is much more efficient if such mental health promotion in schools is carried out collaboratively between the HIV, substance abuse, and mental health teams rather than as separate initiatives.
Partnership With Traditional Healers
Traditional healers are very common across the world (1 per 50 population in sub-Saharan Africa) and will remain a key deliverer of health care for large proportions of the population for many decades if not centuries. Their practice is variable and there is no doubt that some traditional practice is very harmful, but it is also likely that some of the herbal medicines used have helpful psychoactive properties and that some interventions give important psychosocial support to individuals, families, and communities. Rather than seeking to destroy traditional healing, it is more productive to research their provision and outcomes, seek dialogue with the aim of eliminating frankly harmful practices, and engage in joint training using diagnostic algorithms to encourage referral of difficult or chronic cases.
Integration With Primary Care
Primary health care has been defined by the World Health Organization as:
essential health care made accessible to individuals and families in the community, by means acceptable to them, through their full participation and at a cost that the community and the country can afford. It forms an integrated part of the country’s health care system, of which it is the nucleus, and of the overall social and economic development of the country (WHO, 1978).
The rationale for primary care arises from comparison of the prevalence and burden of severe mental illness and the common mental disorders, with the relative availability of specialist services. For example, in the national psychiatric morbidity surveys of Great Britain of 1994 and 2000, 16% of the adult population were suffering from a common mental disorder such as depression and anxiety and 0.5% from psychosis, with one psychiatrist per 50 000 in 1994 and approaching one per 10 000–20 000 population in 2005. Therefore no country, however rich, can afford anything approaching sufficient specialist personnel to see and care for everyone with a mental disorder.
Whatever the country, whether rich or poor, mental disorder is so common that most people with mental disorders will need to be seen and cared for by members of a primary health-care unit. It is therefore essential that both mental health policy and general health sector reforms aim to strengthen the basic and continuing training of primary health-care personnel in assessment, diagnosis, management, and criteria for referral of people to secondary care. This is as essential in the developed world as it is in low-income countries.
In richer countries, people with severe mental illness may be cared for by specialist services, with some shared care with primary care for long-term support. In poorer countries, there may often only be capacity for a small number of people with psychosis to be cared for in specialist care and most will need to be assessed, diagnosed, and treated in primary care, with support from specialist services.
We know from epidemiological studies that there is a high prevalence of common mental disorders in the general population and these may also be severe, disabling, and of long duration. This high prevalence in all countries means that not even rich countries can afford sufficient specialists to look after everyone with a mental disorder.
Because of their high socioeconomic costs, it is not tenable to argue that the burden of common mental disorders should be ignored. These costs arise from the repeated primary care consultations, and if patients remain untreated, absence due to sickness, labor turnover, reduced productivity, and the impact on families and children. Primary care therefore needs to play a central role in overall mental health care in rich countries as well as in poor countries. In addition to the logistical necessity of primary care, primary care has particular advantages in that it allows attention to both physical health and social needs, it allows continuity of care, it is often preferred by consumers, it is often more accessible than specialist care, and studies have shown it is possible to achieve good clinical and social outcomes.
In the development of policy on primary care of mental illness, it is important to examine the existing primary care system, its staffing, its system of basic and continuing training for each of the professional groups involved, and the existing system of information collection from primary care. Some key questions remain:
- Is the lead professional in the team a doctor or a medical assistant or a nurse, and what are their respective roles? For example, in some countries health workers with months rather than years of training are in the front line, dealing with screening and case finding, assessment and treatment. In Pakistan, the first tier are health-care workers, usually married women with grown children, who receive a short training, and the second tier is the primary care doctor. In the UK, the first tier is usually the primary care doctor, although this is now changing in some areas to allow nurses to conduct initial triages. A few still work alone but most work in groups and employ a number of primary care nurses. They also collaborate with a community nursing structure of district nurses and health visitors.
- What does the basic training for each tier and professional in the primary care unit consist of and how much if any mental health is included? For example, in Iran and Pakistan, the village health-care workers receive a few months training in selected priority topics so that they can screen, assess, diagnose, and treat. In Zanzibar, there is a 4-year basic training for all nurses and the fourth year is devoted to mental health.
- What continuing training is available for each tier? In Zanzibar, there are education coordinators whose task is to organize and deliver continuing training for all the staff in the primary health-care units. This continuing training is regular, consisting of several weekends a year for which the primary care staff receive transport allowances and incentive payments to attend.
- What quality monitoring exists in primary care? In Iran, health psychologists perform a quality monitoring role for the village health workers, and visit every month to support, supervise, and check on the quality of the work. Systems for information collection in primary care are needed for adequate planning. This can be effective without involving expensive technology. For example, in Iran, health workers routinely collect and display annual data on prevalence and outcome of priority disorders.
- How proactive should primary care be? Should it mostly concentrate on active consulters or should it take a broader population perspective and seek to find and treat common disabling conditions? Primary care capacity for outreach is important. Transport is necessary for outreach from secondary care to primary care and from primary care to the community. It may need to be subsidized, be appropriate to the terrain, and preferably not be shared with other specialties with different working patterns.
In countries where there is a low psychiatrist-to population ratio, specialists must support primary care to assess and manage all but the most severe cases. Specialists need to spend a major proportion of their time as a supportive consultant advisor (e.g., supervision, teaching, local planning, service development, and researching key local issues) for the service as a whole rather than purely as a hands-on clinician if they are to have maximum impact on the population for which they are responsible and if specialist nurses and primary care teams are to be adequately supported. However, in practice, it is difficult to achieve this when psychiatrists tend largely to be trained for their clinical role rather than for their leadership role in service development, intersectoral partnerships, support and supervision to primary care, etc., and where psychiatrist’s remuneration is often dependent on the clinical role.
The integration of primary and secondary care is assisted by communication, including regular meetings to discuss criteria for referral, discharge letters, shared care procedures, need for medicines, information transfer, training, good practice guidelines, and research, and by agreeing to prescribing policies and ensuring supply of essential medicines.
Logistical consideration of the availability of the specialist services relative to primary care and to the population epidemiology of disorders is essential in order to plan the precise framework for specialist support to primary care.
In low-income countries, there is often only one psychiatrist per million population and in a few countries this is as low as one psychiatrist per five or six million.
Integration Of Mental Health With District-Level And Provincial-Level Health Care
However rich a country may be, specialist mental health staff will nonetheless be in relatively short supply and therefore policy is needed to ensure their efficient deployment. In low-income countries, specialist services are usually in extremely short supply, and it is important to use them to best effect. Often the distribution of specialists is not equitable relative to the population, with most concentrated in the main cities for a variety of reasons, including the availability of private practice, the availability of academic links and posts, and the availability of schools and other facilities for families. For example, in Tanzania over half the country’s psychiatrists live and work in Dar es Salaam. A similar situation exists in Australia and many other countries. Attention therefore needs to be given to the construction of attractive posts that offer exciting and interesting work, are suitable for people with families, but which nonetheless meet the overall service needs of the country. During specialist training and continuing professional development, attention will also need to be paid to the wide range of skills required by specialists responsible for service delivery for large populations, which may range from 500 000 to 5 000 000. Indeed Malawi has only one psychiatrist for its 13 million population. Clearly, service leadership, intersectoral liaison, support from the regional level to the district services, and capacity building at the district level to support and supervise primary care will be crucial components of the leadership role, as well as advocacy and construction of annual operational plans and budgets within the health sector.
The availability of specialist doctors, psychologists, and nurses is even less than it appears because of the time devoted to private practice in order to supplement the basic salary. Apart from availability for direct clinical work, it is also important to consider availability for audit, planning, service development, and essential research. It is therefore important for countries, when determining salary structures, to consider the opportunity costs of losing a significant proportion of a highly trained specialist’s time not just from clinical work, important though it is, but also from the strategic planning and service development function, which is also essential.
There is growing concern that relatively rich countries are increasing their relative proportions of specialists per head of population, not so much by training greater numbers of specialists, but rather by recruiting trained specialists from low-income countries who can ill afford to lose them. It is crucial that governments agree on international guidelines to prohibit active poaching from low and middle-income countries, and to give adequate recompense to governments in low and middle-income countries for the loss of their health-care workers, both for their training and for the opportunity costs of losing such people often at a relatively senior stage in their careers.
Policy On Planning And Resourcing Specialist Services
To achieve good outcomes, people with severe mental illness should be cared for as close to home as is compatible with health and safety of the individual and the safety of the public, in an environment that is the least restrictive possible, with due regard to their rights as human beings and respect for their dignity, religion, and culture. The precise service structure and configuration needs to be determined in the context of local needs, culture, and resources, and in the West may include a small flexible mixture of acute inpatient beds, halfway houses, respite houses, outpatient clinics, occupational rehabilitation, day care, employment, and social activities aimed at promoting each individual’s self-determination and personal responsibility. In low-income countries, resource constraints greatly limit the extent of specialist provision, which may be limited to district level outpatient clinics, and very small numbers of inpatient beds in the provincial hospitals (e.g., 20 beds per 5 000 000 population). Some countries with a colonial history have inherited a large national mental hospital, which is usually being downsized and converted to other uses such as training. Attention needs to be paid to the appropriate siting of inpatient beds so that relatives can visit frequently. Apart from maintaining emotional links with the family, in poor countries, relatives are relied on to make significant contributions to the patient’s diet and patients may become significantly malnourished without such input. Where the only beds available are hundreds of miles away, it is all too easy for family ties to be disrupted, contributing to long-term institutionalization.
Before planning future service developments, it is crucial to assess the existing specialist services, their distribution relative to the population, their balance, and their current pattern of use. Where large asylums exist, they tend to be in poor repair, with inadequate resources for maintaining the fabric of the building, staffing, treatment, and rehabilitation. Policy needs to consider the future of such asylums, which research has shown encourage institutionalization and the accumulation of significant social handicap. There is an inevitable tension between putting resources into developing a range of local services in each locality, however defined, and continuing to put adequate resources into the asylum until it can close. In essence, it is necessary to provide double running costs for a period of time. In practice, most governments do not budget for double running costs and this leads in many countries to the existence of mental hospitals, which are in a far worse state of repair than the general hospitals, with worse staffing, training, and worse morale, and even too few resources to give the patient an adequate diet. It is therefore essential for policy to address the mechanics and time scale, resourcing of the transition period, and to build in adequate monitoring of progress.
In some countries, most acute admissions are to general beds in general hospitals where the patients are cared for by general nurses. If this is the case, policy needs to consider how far the quality of care can be improved by additional training for the general nurses.
Key Service Provision Issues
Supply Of Essential Medicines And Therapies
It is important to assess the needs for essential medicines and basic psychosocial interventions; even though there is a significant cost attached to ensuring adequate availability of medicines and psychological treatments. Nonetheless if there is adequate availability of treatments in primary care, then the number of inpatient beds needed in the new community-oriented system will be much smaller than that originally provided in the asylums. In some countries, senior policy makers do not recognize that mental illness is a real illness or that it can be treated, or that not to do so incurs considerable financial and social costs to the country. This attitude leads to inadequate provision for essential medicines in the medication budget.
Basic psychosocial interventions include general support, cognitive behavior therapy, marital therapy, psychological education, and relapse prevention. Occupational therapy is especially important. All inpatients should be in an appropriate rehabilitation and activity program every day.
Where countries cannot afford a wide variety of different specialists, it is not uncommon for one professional to fulfill a variety of roles. For example, the psychiatric nurse may take on the role of occupational therapist or social worker. If this is the case, then policy needs to consider how far the basic training of psychiatric nurses should take into account and support this situation by incorporating modules on occupational therapy and social work.
Standards Of Care
Where patients are cared for in places other than their own homes, it is essential to have some system of quality assurance to ensure that some basic standards are met. For example, it is reasonable to expect an adequate diet, adequate spacing of meals, hygienic cooking facilities, and hygienic washing and toilet facilities, with appropriate privacy and freedom from sexual harassment for women. It would not be realistic to expect low-income countries to be able to afford the kinds of inspection that richer countries can deploy, but it is reasonable to expect that psychiatric hospitals be regularly visited by senior politicians, policy makers, and influential lay people so that the conditions in the hospital are clearly known and visible.
Good practice guidelines are helpful educational tools for ensuring that best practice is routine and may be useful in inpatient, outpatient, and community settings. All referred patients will need routine assessment of the physical, psychological, and social needs and a care plan to meet those needs (e.g., Jenkins, 2004b).
Provision For Women
Women, by virtue of their increased exposure to acute life events, chronic social stresses, lower social status and income, and smaller social networks, are often particularly vulnerable to common mental disorders. There is also a small group of disorders specific to women, disorders associated with menstruation, pregnancy, and childbirth. Governments will therefore need to consider access to education, training, and health care for women as well as the influence of other government policies on these issues. Liaison between government departments on policies to improve family cohesiveness, for example, mechanisms such as taxation and welfare benefits in place to support families, reduce family breakdown, and reduce the burden on women as they struggle to raise their children will impact on mental health. In some countries, mental illness is a sufficient reason for divorce, and such premature divorces will often leave a parent without financial support, to the detriment of both the mother and the child. It is therefore important to make available marital support and therapy. This is an activity that can often be usefully delivered by a nongovernmental organization.
Provision For Children
Children are a nation’s most precious resource, yet services for children and adolescents are often the least developed and supported. Children’s cognitive and emotional development is greatly influenced by the mental health of their parents, especially the mother, and particularly when the mother is the main carer. In addition to the general rates of adult illness, women experience higher rates of illness around the time of childbirth. If untreated, these disorders can severely affect the mother’s relationship with her children, thus damaging the child’s cognitive and emotional development. Particular childhood disorders that need to be considered include emotional and conduct disorders, epilepsy, mental retardation, cerebral malaria, and specific learning problems such as dyslexia.
It is important to develop facilities for sick postnatal mothers to be cared for with their babies, and older children with their mothers. All children with epilepsy should receive adequate medication (often in very short supply in low-income countries) and school teachers should receive training in detecting and managing dyslexia, which is a significant contributor to conduct disorders and depression in children and to antisocial behavior in adult life.
Children and adults with cognitive disabilities should be able, encouraged, and supported to lead as normal a life as possible. Children with cognitive disabilities, as well as those with special educational needs, often also have social, physical, and psychological needs. This means that close liaison between the ministries of health and education is important. Policy makers will need good estimates of the prevalence of cognitive disabilities, and an appreciation of the possibilities for prevention of some cases, for example in areas where iodine deficiency is a significant cause, such as Cambodia. Many children with cognitive disabilities also have specific neurological problems such as cerebral palsy and epilepsy, and essential medicines are needed to ensure that the cognitive deficit is not aggravated by these associated conditions.
The psychiatric services need to plan how they can deliver an assessment and management service to children with cognitive disabilities and their care providers. There also needs to be an orientation to the needs of children and adults with cognitive disabilities and their families in primary health care. This may be supported by the use of good practice guidelines on assessment and management of cognitive disabilities. Depending on the availability of resources, consideration needs to be given to the training of child psychologists, speech therapists, and special teachers and to the incorporation of cognitive disability into basic, specialist, and continuing training.
Public Health Measures
Reduction Of Suicide And Homicide By Mentally Ill People
Government health policies usually implicitly, or sometimes explicitly, aim to protect, promote, and improve health and to reduce premature avoidable mortality. Premature death from suicide is a significant cause of mortality around the globe; official suicides alone form the tenth leading cause of death in the world, equivalent in magnitude to deaths from road traffic accidents or to deaths from malaria. A number of countries are now developing national suicide prevention policies (United Nations, 1996; Anderson and Jenkins, 2008).
Psychiatric homicide prevention programs will include improved training in risk assessment, improved coordination, continuity of care, and communication between care providers and improved provision of support for those in greatest need, particularly the provision of 24-h nursing care for people in whom a lesser degree of support is insufficient.
Reduction In Mortality From Physical Illness In Mentally Ill People
People with severe mental illness tend to have a higher mortality than the general population from cardiovascular disease, respiratory disease, and malignancy. It is therefore extremely important to ensure adequate physical health care and health promotion to people with mental illness, particularly those being looked after by the hospital. In tropical countries this may include particular public health attention to the quality of the water supply and sanitation to reduce the risk of cholera, for example. In cold countries, this will include particular attention to housing.
Preparedness For Disasters
No country can afford to ignore the possibility of disasters, whether instigated by humans or natural. More than 50 countries have experienced conflict in the last 20 years. Conflicts are much more common in poor countries, and 15 of the 20 poorest countries of the world have had a major conflict in the last 15 years. Nearly all low-income countries are next to a country that has experienced war and therefore frequently carry the burden of caring for refugees. Women and children are particularly vulnerable to war, frequently being witness to or forced participants in murder, victims of rape, victims of infection with AIDS, rejection, abduction of child soldiers, with the subsequent difficulty rehabilitating them.
Psychosocial issues are often neglected in post conflict situations even though the presence of psychosocial disorders contributes to low compliance with vaccination, nutrition, oral rehydration, antibiotics, and risky sexual behavior, and hence to the high morbidity and mortality from preventable and treatable infectious disease.
Sometimes the sheer volume of refugees and their movements make practical arrangements very difficult. For example, in Macedonia during the Kosovo crisis, there were over 250 000 refugees and large transfers at short notice between camps as new refugees arrived, making psychosocial work very difficult during the initial phase. In Kashmir, the affected population was extremely widely dispersed through vast mountain areas and did not want to abandon their homes to be centralized into camps. Therefore, primary care is crucial in disaster management, and the central importance of involving primary care teams in the management of the medium and long-term psychological consequences of a disaster has long been argued. In any disaster affecting large numbers of people, there will be preexisting disorders, the severity of which have been exacerbated by the disaster, and there will be new disorders caused by the disaster. Thus, the whole range of mental disorders (psychosis, common mental disorders, childhood disorders, dementia, substance abuse) as well as common neurological problems such as epilepsy need to be addressed, not just PTSD. Disasters often uncover or highlight preexisting public deficiencies and problems, such as the lack of a preexisting strong primary care and public health system; consequently, much of the postdisaster task is in fact the construction of what should have been in place before the disaster, namely the establishment of a strong primary care system, supported by decentralized district specialist services, and mechanisms for intersectoral liaison. Experience indicates over and over again that countries beset by disaster then undergo a second disaster, which is the lack of coordination by the multiple agencies who respond to disasters. Coordination is crucial, and all assisting agencies must liaise closely with the WHO country office and government ministries who have the overall lead responsibility (see Inter-agency Standing Committee, 2007).
Implementation Of Policy
Implementation is even more challenging than strategy formulation, and particular attention needs to be paid to:
- Communications: Public relations on strategy, cascading information within organizations, organizing feedback, and alliance-building between key partners;
- Resources: Accessing key budgets, securing capital, ensuring revenue flows, maximizing the use of generic budgets, sponsorship, and aid;
- Staff: Planning the development of the human resource, training for changing service configurations, basic and continuing education for mental health staff, training generic staff such as primary care and teachers, communicating with staff, engaging professional bodies and educational institutions;
- Embedding the strategy: Engaging generic organizations, managers, politicians;
- disseminating good practice;
- Implementing an R & D strategy: Including evaluation, learning from mistakes, and successes and finetuning of strategy, quality assurance, accreditation, and inspection;
- Addressing stigma: There is a need to address high-level stigma within government surrounding mental health so that mental health policy is well integrated with general health policy and so that de-institutionalization is seen as an important step toward achieving better health and social outcomes for people with mental illness, but not as an opportunity to save money on the costs of health care;
- Political will: Political will at national level is essential to support mental health in public policy and must include a high profile for mental health within the ministry of health, liaison with other ministries and a cabinet committee for mental health; political will at international level will foster debate in the international media and international cooperation.
An important component of the way forward includes building capacity for policy development, health monitoring, research architecture, for innovation, development, and empowering leadership. This means creative use of attachments and secondments during training and career development. It is important to know much more about national and local epidemiology and to build capacity in local epidemiology.
The Facilitating Role Of International Agencies In Stimulating Policy Development
In 2001, WHO devoted both its annual health day and its annual health report to mental health, which called on countries to develop mental health policies. In the same year, the Institute of Medicine, in Washington, launched a scientific report on neurological, psychiatric, and developmental disorders in low-income countries, which called for immediate strategic action to reduce the burden of brain disorders (Institute of Medicine, 2001). The EC plays an important role both in Europe and elsewhere and has recently produced a public health framework for mental health. At national level, various governments, national NGOs, professional bodies, and the media have played important roles in prioritizing mental health in their countries.
All countries have a mixture of developed and developing features, and we can learn from each other. Large-scale applications are dangerous and we need locally tailored solutions. We need to build capacity for strategic policy work, tackle stigma, enhance human rights, consumer involvement, individual assessment of needs and individually tailored care plans, evidence of interventions, public relations, and evaluation of outcomes. Psychiatrists have a key role to play in influencing their governments to increase the priority afforded to mental health, develop well-tailored mental health policies, and support their implementation and fine-tuning. It is therefore essential that every country create a strategic mental health policy that is well integrated, both with its general public policies and its overall health policy at ministerial, regional, and local levels and that covers the three broad tasks:
- Community action to promote mental health;
- Primary care of mental disorders for prevention and prompt and efficient treatment of common mental health disorders;
- Specialist services (as local as is affordable) to support those patients in greatest need and to support and sustain expertise in primary care.
Mental health in a population depends on much more than the policies of the health and social services, and is influenced by policies on housing, employment, taxation, and issues such as the availability of alcohol. Policy is likely to work best if it is integrated as far as possible with existing systems for education, human resources, organizing feedback, and alliance building between key partners.
It needs to be accompanied by a strategic implementation program, a timetable for action, and substantial political will. It is essential to access key budgets, secure capital, ensure revenue flows, maximize the use of generic budgets as well as specific budgets, and obtain sponsorship and aid. Mental illness is stigmatized and suffers from lack of resources everywhere. Giving it its own budget gives it status and visibility.
The best of plans will remain on the shelf unless a powerful strategic mechanism is devised for their implementation with direct senior official and ministerial accountability. The implementation strategy needs to address all levels of action, at the national, regional, and local level, including the specialist sector, primary care sector, and the community.
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