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Action based on resource realities

Chapter 5 Providing effective solutions Overall recommendations Action based on resource realities

While they are generally applicable, most of the above recommendations may appear to be far beyond the resources of many countries. But there is something here for everyone. With this in mind, three separate scenarios are provided to help guide developing countries in particular towards what is possible within their resource limitations. The scenarios can be used to identify specific actions. As well as being relevant to individual countries, they are also intended to be relevant to different population groups within those countries. This recognizes that there are disadvantaged areas or groups in all countries, even those which have the best resources and services.

While they are generally applicable, most of the above recommendations may appear to be far beyond the resources of many countries. But there is something here for everyone. With this in mind, three separate scenarios are provided to help guide developing countries in particular towards what is possible within their resource limitations. The scenarios can be used to identify specific actions. As well as being relevant to individual countries, they are also intended to be relevant to different population groups within those countries. This recognizes that there are disadvantaged areas or groups in all countries, even those which have the best resources and services.

Scenario A (Low level of resources)

This scenario refers mostly to low income countries where mental health resources are completely absent or very limited. Such countries have no mental health policy, programmes or appropriate legislation; or, if they exist, they are outdated and not implemented effectively. Governmental finances available to mental health are tiny, often less than 0.1% of the total health budget. There are no psychiatrists or psychiatric nurses, or very few of them for large populations. Specialized inpatient care facilities, if they exist, do so as centralized mental hospitals, which serve more for custodial care than mental health care, and often have less than one place per 10 000 population. There are no mental health services in primary or community care, and essential psychotropic drugs are seldom available. Mental health is not a part of epidemiological and health reporting systems.

While this scenario applies mostly to low income countries, in many high income countries essential mental health services remain beyond the reach of rural populations, indigenous groups and others. In brief, scenario A is characterized by low awareness and low availability of services.

What can be done in such circumstances? Even with very limited resources, countries can immediately recognize mental health as an integral part of general health, and begin to organize the basic mental health services as a part of primary health care. This need not be a costly exercise, and it would be greatly enhanced by the provision of essential neuropsychiatric drugs and in-service training of all general health personnel.

Scenario B (Medium level of resources)

In countries in this scenario, some resources are available for mental health, such as centres for treatment in big cities or pilot programmes for community care. But these resources do not provide even essential mental health services to the total population. These countries are likely to have mental health policies, programmes and legislation, but they are often not fully implemented. The government budget for mental health is less than 1% of the total health budget. There are inadequate numbers of mental health specialists, such as psychiatrists and psychiatric nurses, to serve the population. Primary care providers are largely untrained in mental health care. Specialized care facilities have fewer than five places per 10 000 population, and most of these are in large and centralized mental hospitals. Availability of psychotropic drugs and treatment for major mental disorders in primary care is limited and community mental health programmes are scarce. Admission and discharge records from mental hospitals provide the only information available in health reporting systems. To summarize, scenario B is characterized by medium awareness and medium access to mental health care.

For these countries the immediate action should be to enlarge mental health services to cover the total population. This can be done by extending training to all health personnel on essential mental health care, providing neuropsychiatric drugs in all health facilities, and bringing all of these activities under a mental health policy. A start should be made on closing down custodial hospitals and building community care facilities. Mental health care can be introduced in workplaces and schools.

Scenario C (High level of resources)

This scenario relates mostly to industrialized countries with a relatively high level of resources for mental health. Mental health policies, programmes and legislation are implemented reasonably effectively. The proportion of the total health budget allocated to mental health is 1% or more, and there are adequate numbers of specialized mental health professionals. Most primary care providers are trained in mental health care. Efforts are made to identify and treat major mental disorders in primary care, though effectiveness and coverage may be inadequate. Specialized care facilities are more comprehensive, but most may still be located in mental hospitals. Psychotropic drugs are readily available and community-based services are generally available. Mental health forms a part of health information systems, although only a few indicators may be included.

Even in these countries there are many barriers to the utilization of the available services. People with mental disorders and their families experience stigma and discrimination. Insurance policies fail to provide cover for the care of people with mental disorders to the same extent as for those with physical illness.

The first immediate action required is to increase public awareness, aimed principally at decreasing stigma and discrimination. Second, the newer medicines and psychosocial interventions should be made available as part of routine mental health care. Third, mental health information systems should be developed. Fourth, research on cost-effectiveness, evidence on prevention of mental disorders, and basic research on causes of mental disorders should be initiated or extended.

The recommended minimum actions required for mental health care in the three scenarios are summarized in Table 5.1. The table assumes that the actions recommended for countries in scenario A have already been taken by countries in scenarios B and C, and that there is an accumulation of actions in countries with high levels of resources.

Table 5.1 Minimum actions required for mental health care, based on overall recommendations

This report recognizes that, in all scenarios, the time lag between initiation of actions and their resultant benefits can be long. But this is an added reason to encourage all countries to take immediate steps towards improving the mental health of their populations. For the poorest countries, these first steps may be small, but they are nonetheless worth taking. For rich and poor alike, mental well-being is as important as physical health. For all who suffer from mental disorders, there is hope; it is the responsibility of all governments to turn that hope into reality.

Chapter 5: The Way Forward: 1,2,3