Why integrating mental health into Universal Health Coverage in low resource settings is necessary and achievable

Mental health problems are some of the most challenging areas of health, but there are steps we can take to ensure they get the necessary attention – and a place within Universal Health Coverage (UHC). Ahead of the UN High-Level Meeting on UHC being held on 23 September, Prof Shekhar Saxena, Distinguished Fellow of The George Institute for Global Health and past Director of the Department of Mental Health and Substance Abuse at World Health Organisation explains why we need to remember the ‘five I’s’ to support implementation.

Mental health problems remain some of the most neglected areas of health, with the vast majority of people with mental disorders having no access to care whatsoever. The situation in low and middle income countries is especially alarming, as this ‘treatment gap’ reaches more than 90 percent in some cases, even for readily treatable conditions like depression. As world leaders gather at the United Nations next week to discuss Universal Health Coverage (UHC), it is time to make a strong case for the inclusion of mental health on this high level global agenda and to secure commitments from governments, especially from low and middle income countries, to addressing these gaps in policy, clinical practice and research.

The World Health Organization defines Universal Health Coverage (UHC) as a scenario where: all people have access to the health services they need (including prevention, promotion, treatment, rehabilitation and palliation), these services are of sufficient quality to be effective, and the use of these services does not lead to financial hardship. The United Nations Sustainable Development Goals (SDGs) include achieving UHC as a target under goal 3 (ensure healthy life and promote wellbeing for all at all ages). UHC is also one of the cross-cutting principles of Comprehensive Mental Health Action Plan of WHO, adopted by the World Health Assembly. Importantly, the ‘H’ in ‘UHC’ has to be interpreted within the context of physical, mental and social wellbeing, as per the definition of health globally agreed more than 70 years ago.

As countries and communities struggle to allocate adequate resources towards increasing health costs, including mental health within the UHC package seems a challenge, particularly for LMICS. However, there is increasing and compelling evidence that mental disorders are common in all regions, countries and communities, they cause a large amount of disability and negative economic impact, and cost-effective interventions exist for these disorders. The disparities between health care resources allocated for physical versus mental disorders are large, with most low and middle income countries spending less than 1 percent of their health budget on mental health. Using evidenced-based interventions in the care of people with mental disorders also makes economic sense - the return on investment for depression and anxiety disorders is very positive indeed. So no country can afford not to invest in mental health as part of UHC packages.  In addition, the equity and human rights case for the care of people living with mental disorders is especially strong, since stigma and discrimination have been all-pervading in most cultures and communities.

Accepting mental health as an integral component of UHC is only the first step. Addressing the ‘how’ is extremely important, particularly for low resource settings which have a number of limitations in integrating mental health within UHC and need to plan implementation diligently for this to be successful. The following actions (the five ‘I’s) provide a framework to support implementation of mental health as part of UHC.

1. Increase resources: Financial and human resources for mental health care will need to increase several-fold in almost all low and middle income countries for mental health care to become accessible by all. The arbitrary but realistic target of allocating 5 percent of the health budget in low and middle income countries for mental health care should be achieved well within the timeframe of SDGs. Countries also need to plan for developing, within specific time frames, teams of specialists and other health personnel with clear responsibility for providing mental health care services.
    
2. Integrate services: Mental health services in most low and middle resource settings have remained isolated from overall health services. Old-style custodial mental hospitals built outside cities are an example of this phenomenon. UHC provides an unprecedented opportunity to integrate mental health services with those for physical health. This will bring mental health services back to the community where they belong, increasing access and reducing stigma. Integration needs to be at all levels, from community health workers through to specialized care.
    
3. Innovate on delivery of care: Innovations in the delivery of mental health care are needed everywhere, but are absolutely essential in low resource settings. Basic mental health care needs to be delivered within the primary care setting by trained health workers and non-specialist professionals following the strategy of task-sharing. But we know that simply training primary care personnel doesn’t work. Providing adequate and sustained support as well as supervision is a must. This is where system-level change needs to occur, with inbuilt incentives and ongoing monitoring. Another innovation is use of technology, which can increase access as well efficiency in a variety of ways - including distance training, consultations and supervision of providers - but also open up space for online access to evidence-based psychological interventions. Many examples of innovations in delivery of mental health care in low resource settings are available.
    
4. Include persons with lived experience: Persons with lived experience of mental disorders have, at best, simply been on the receiving end of whatever services were offered to them. Often they were incarcerated against their will and stripped of their basic human and civil rights. Mainstreaming mental health services within UHC provides an opportunity to include service users in designing the care they need and even engaging them in actual delivery as peer care-providers. It is worth noting that networks of people with lived experience have become stronger globally and nationally.
    
5. Inform on progress: Monitoring and accountability mechanisms will need to be strengthened if the objective of universal access to mental health care is to be fulfilled. Most low and middle income countries do not include mental health indicators in their health information systems, without which they have no means of knowing what the existing and emerging needs and demands are, and to what extent they are being met. These countries will need to build the capacity to monitor the mental health of their population, the services that their health care system is providing and the impact they have. This will also have the benefit of enhancing accountability for the resources that are needed. Evidence on the most effective and feasible indicators has accumulated and a new consortium has been developed to enhance monitoring and accountability at a global level.

Promoting mental health and wellbeing is important for everyone. Integrating mental health care within universal health coverage provides an opportunity to further this pursuit. While a stronger global commitment will help, some careful planning and implementation will be needed to make true integration a reality in low resource settings.

References:

1. Thornicroft, G. et al (2017) Undertreatment of people with major depressive disorder in 21 countries. British Journal of Psychiatry, 210, 119-124.
2. Patel V, Saxena S (2019) Achieving universal health coverage for mental disorders. BMJ 2019;366:l4516
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4. Sustainable Development Goals 
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8. Mental Health Atlas 
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13. Mental health Innovators 
14. Global Mental Health Peer Network
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